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.

Note:  Fields in red with asterisk are required

Claimant Information
Name:

Address:

City/State/Zip:

Date of Injury:

Your Information
Name*:

Claims Examiner:

Email*:

Telephone:

Address:

City/State/Zip:

Claim Number:

Employer
Name

Address:

City/St/Zip:

Insurer (if applicable)
Name:

Court Information
Court:

Case Number:

Claimant Attorney Information (if represented)
Name:

Address

City/St/Zip

Phone:

Referral Instructions/Remarks / Comments

Venue


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