Benthale, McKibbin & McKnight Case Referrals

Litigation Referral Sheet

The Law Offices of Benthale, McKibbin & McKnight would be pleased to provide Workers Comp Defense assistance. Please fill out the on-line form and we will contact you immediately.

Case Information		Status
Date:		Rush:
Claim No:		If Rush (Reason)
Date of Injury:		Hearing Date:
WCAB No:		Denial Date:
Office:		Other:
Attorney:

Applicant Information
Applicant:		Represented By:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
DOB:		Area Code/Phone:
SS#:
Occupation:

Employer		Referred By
Insured:		Company:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
Area Code/Phone:		Area Code/Phone:
Total Coverage:		Email:	(E-mail)
Weekly Comp Rate:		Contact:
Total TD Paid:
TD Periods Paid:
Total Medical Paid:

Case Documents:	(Max file size 10mb PDF, Word or WordPerfect document)
Suggested Issues/Comments: