Litigation Case Worksheet by erk17631

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									                       TROVILLION, INVEISS & DEMAKIS
 SAN DIEGO COUNTY OFFICE          ORANGE COUNTY OFFICE                LOS ANGELES OFFICE                RIVERSIDE OFFICE
   FAX: 619-232-8423               FAX: 714-547-3355                   FAX: 626-247-1184                 FAX: 951-300-9014



                                        Litigation Referral Worksheet
YOUR NAME:_____________________________________ PHONE:________________________FAX:____________________
COMPANY NAME: _________________________________________________________________________________________
INSURER’S CORRECT NAME________________________________________________________________________________
ADDRESS:_________________________________________________________________________________________________
SELF INSURED EMPLOYER ______________________________________________ CLAIM #__________________________

                                               Case Information
                    CA Worker’s Comp     Subrogation     132 (a)      S&W        LHWCA              Other
EMPLOYEE:__________________________________________             DOB:______________ OCCUPATION:________________
EMPLOYER:____________________________________________________ POLICY PERIOD: __________________________

DATE OF INJURY:_____________________________         BODY PARTS ______________________________________________
EMPLOYEE’S ATTORNEY: __________________________________________________________________________________
ADDRESS: __________________________________________________________________ TELEPHONE: __________________

CLAIM FORM RETURNED ON: _________________________                APPLICATION FILED ON: __________________________
DENIAL LETTER ISSUED ON: __________________________              ANSWER FILED ON: _______________________________
                                                                                             FILE ANSWER:        YES         NO
** PLEASE ATTACH COPIES OF ALL CLAIM FORMS PROVIDED TO EMPLOYEE.



                 Benefits Paid                                        Suggested Issue
   TD $ ____________ RATE ______________
   PERIODS _____________________________                1.    INJURY AOE/COE     11.   STATUTE OF LIMITATIONS
   PD $_____________ RATE ______________               2.     EMPLOYMENT         12.   JURISDICTION
                                                       3.     OCCUPATION         13.   DEPENDENCY
   PERIODS _____________________________               4.     COVERAGE           14.   SUBROGATION
   VRMA ___________RATE ______________                 5.     EARNINGS/AWW       15.   132 (a)
                                                       6.     TEMP DISABILITY    16.   S&W
   PERIODS _____________________________               7.     PERM DISABILITY    17.   CONTRIBUTION
   MEDICAL EXPENSES $_________________                 8.     APPORTIONMENT      18.   8F
                                                       9.     PAST MEDICAL       19.   RESIDUAL WAGE EARNING CAPACITY
   VR EXPENSE $ ________________________               10.    FUTURE MEDICAL     20.   OTHER




                Defense Discovery Athorized:
                DEPOSE APPLICANT:        YES    NO           NEED TO DISCUSS

                SCHEDULE MED EXAM:       YES    NO           NEED TO DISCUSS   PHYSICIAN:________________________________

                SUBPOENA RECORDS:        YES     NO          NEED TO DISCUSS    SOURCE:___________________________________


                                                               Comments:_____________________________________
                                                               ________________________________________________
                                                               ________________________________________________
     Signature: __________________________________             ________________________________________________
     Date: ______________________                              ________________________________________________
                                                               ________________________________________________

								
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