Submit a Case "*" indicates required fields Referrer’s Contact InformationReferrer's Email Address* Full Name of Insurer*Date of Referral* MM slash DD slash YYYY Fee ArrangementContingentHourlyClaim Number*Workers' Compensation Adjuster Email Workers' Compensation Adjuster PhoneSubrogation Adjuster Email Subrogation Adjuster PhoneNew Loss InformationDate of Loss MM slash DD slash YYYY Loss LocationBenefit StateSelect a stateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAdverse Party/Parties (if known)Brief Description of LossInclude names and contact information for any known witnesses.Nature Of InjuryCheck all that apply Fatality Amputation Head Injury Internal Injury Vision Impairment Hearing Impairment Paralysis Crush Fracture Burn Disfigurement Laceration Puncture Exposure/Inhalation Other Medical Benefits PaidSelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Indemnity Benefits PaidSelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Employer/Insured InformationFull Employer Name*Contact PersonEmail PhoneInjured Worker's InformationFirst Name* First Last Name* First Spouse or Contact PersonPhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Counsel Representative for Injured WorkerThird-Party Counsel NameThird-Party Counsel PhoneThird-Party Counsel Email Workers’ Compensation Counsel NameWorkers’ Compensation Counsel PhoneWorkers’ Compensation Counsel Email Upload Claims File Documents Drop files here or Select files Max. file size: 50 MB. CommentsImportant Notice Regarding Case Referral SubmissionsSubmitting information through this online referral form does not establish an attorney-client relationship between you and DSB&C or any of our attorneys. Please do not include confidential or sensitive information in your submission until you have spoken directly with one of our attorneys and formally established a privileged attorney-client relationship. If you are not presently a client of DSB&C, any information you provide through this form may not be protected by attorney-client privilege. This referral portal and our invitation to contact us should not be interpreted as a solicitation for legal services or as creating any attorney-client relationship. Additionally, this should not be construed as confirmation that our attorneys are available to provide legal representation in jurisdictions where they are not licensed to practice law. By completing and submitting this referral form, you acknowledge that you have read, understood, and agree to these terms and conditions.
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