Litigation File Referral Form (Luna, Levering & Holmes)

Litigation Referral

* Referral Date:

* Referral Type	Full file referral Walkthrough only**

Case Information

* Applicant:

* Employer:

* Adjuster:

Insurance Company:

Third Party Administrator:
Applicant's Attorney:

Date(s) of injury:

Claim Number(s):

WCAB Case Number(s):

Venue:

Body Part(s):

Applicant's Information

Date of Birth:

Occupation:

Average Weekly Wage:

Temporary Disability Rate:

Permanent Disability Rate:

Issues

Other Issue:

Pertinent Information

Is there a decision date?	Yes, there is a decision date. No, there is not a decision date.

If yes, please list the decision date(s) and date(s) of injury:

Is there an AME/QME?	Yes, there is an AME/QME. No, there is not an AME/QME.

If yes, please list the name(s) of doctor(s):
If yes, please list the evaluations scheduled (if applicable):

Are there any Hearings on calendar?	Yes, there are Hearings on calendar. No, there are no Hearings on calendar.

If yes, please list the Hearing information:

Are there any Depositions scheduled?	Yes, there are Depositions scheduled. No, there are no Depositions scheduled.

If yes, please list the Deposition information:
If no, would you like us to schedule the applicant's Deposition?	Yes, I would like you to schedule the applicant's Deposition. No, I would not like you to schedule the applicant's Deposition.

Additional Information

If there is any additional information you would like us to include, please provide below. Also, if there is any immediate action you would like us to take, please indicate below.

* Email Address:

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