Referrals

Please note that our firm does not represent employees. If you are an injured worker, please do not submit a referral form to our firm.

By submitting this form, you understand that this information is being submitted only so that it may be reviewed and considered by The Law Offices of Schlossberg & Umholtz. Submitting this form does not establish an attorney client relationship and does not obligate us to represent you. We may or may not be able to undertake representation on your behalf, but we will gladly review the information you provide and respond to you. If we are unable to assist you, we may be able to help you by trying to refer your matter to a firm that can.

 

    Claimant Information
    Name:
    Your Information
    Name: (REQUIRED)
    Address:
    Claims Examiner:
    City/State/Zip:
    Email: (REQUIRED)
    Date of Injury:
    Telephone:
    Employer
    Name:
    Adress
    Address
    City/State/Zip
    City/State/Zip
    Claim Number
    Claimant Attorney Information (if represented)
    Name:
    Insurer (if applicable)
    Name:
    Address
    Court Information
    Court:
    City/State/Zip:
    Case Number
    Phone:
    Referral Instructions/Remarks / Comments
    Venue