Graves Bourassa Rippinger & Kempner
Litigation Referrals
Office Location
Please check appropriate office location.
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Adjuster
Carrier or Administrator
Applicant
Employer
WCAB Number
Claim Number
Date of Injury
MM
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DD
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YYYY
Beginning Coverage Period (PSI Period)
MM
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DD
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YYYY
Ending Coverage Period (PSI Period)
MM
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DD
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YYYY
Employment Period Beginning
MM
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DD
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YYYY
Employment Period Ending
MM
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DD
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YYYY
Average Weekly Wages
Why Terminated (TD)
TD Paid $
TD Paid From
MM
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DD
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YYYY
TD Paid To
MM
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DD
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YYYY
TD Rate $
PD Paid $
PD Paid From
MM
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DD
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YYYY
PD Paid To
MM
/
DD
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YYYY
Litigation Referral Sheet
Suggested Issues (Please Check)
Medical Preparation
Original Medical Reports are:
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Remarks:
Contact email address
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