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