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Mullen & Filippi Office and Attorney Preference
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Claimant
Name
Address
City
Phone
Date of Birth
Claimant Employer
Name
Address
City
Carrier
Date of Injury
Claim Number
WCAB Number
Claimant Attorney
Name
Address
City
Phone
Fax
Claims Examiner
Claims Examiner
E-mail Address
Company
Address
City
Phone
Fax
Apparent Reasons for Litigation
(Check any number of reasons below)
Compensation Not Paid
Disability
Medical Treatment
Injury AOE/COE
Statue of Limitations
Average Earnings
Occupation
Coverage
Disputed
Dependents
Subrogation
Notes
Disclaimer:
Please note Mullen & Filippi provides for the online referral of new matters as a convenience to our clients. The Firm will file and serve our formal notice of representation of your interests in a pending matter only upon receipt of complete file information, including pleadings and notices, and upon our completion of a conflict of interest check. Until notice of representation is filed and served, Mullen & Filippi can assume no duty to represent your legal interests. A representative of the Firm will contact you within 24 hours (or the next work day) to obtain the additional information necessary to perform a conflict check and determine if it is appropriate to represent your interests.
By clicking
Submit Referral
you agree to the above disclaimer.
