Phone: (949) 656-4601 support@adelsonmclean.com

Home
About Us
Our Team
Practice Areas
Refer A Case
Resources
News
Contact Us

Select Page

New File Referral

To refer a new file, please fill out the electronic form below. You may also download the paper form and fax it to 949-656-4223, or send it via email to referrals@adelsonmclean.com. If you would prefer to discuss the referral via telephone, please call 949-656-4601.

Adelson McLean - Litigation Referral Form

Examiner Information

Examiner Name *

Examiner Phone *

Company Name

Examiner Address *

Examiner Email *

Case Type

Case Type: *

Workers' Compensation

Subrogation

Civil Litigation

OtherOther

Notes on Case Type

Court *

Case Number *

Is this case on calendar for hearing or deposition? *

Yes

No

Scheduled Date/Time

Scheduled Location

Claimant Information

Claimant Name *

Claimant Address *

Date of Injury *

Employer Name

Employer Address

Claimant Attorney

Attorney for Claimant

Phone for Attorney for Claimant

Address for Attorney for Claimant

Insurance Information

Insurance Carrier *

Claim Information & Status

Claim Number

Has this claim been:

Admitted

Denied

Date Complaint Served

Decision Date

Date of Denial

Answer Date

Benefits Paid

Temporary Disability

Permanent Disability

Medical

Suggested Issues

Check any issues that apply: *

AOE / COE

Parts of Body

Earnings

Temporary Disability

Permanent Disability

Coverage

Employment

Jurisdiction

Statute of Limitations

S&W

LC 132A

Preferred Attorney

Preferred Attorney Name

Comments

Share documents

Upload document #1

Maximum upload size: 516MB

PDF files preferred

Upload document #2

Maximum upload size: 516MB

PDF files preferred

Upload document #3

Maximum upload size: 516MB

PDF files preferred

Upload document #4

Maximum upload size: 516MB

PDF files preferred

If you are human, leave this field blank.

Copyright © 2020 - ADELSON McLEAN

Share This

Twitter