Submit a Case - Derrevere Stevens Black & Cozad

Referrer’s Contact Information

Referrer's Email Address*

Full Name of Insurer*

Date of Referral*

Claim Number*

Benefit State*

Adjuster Responsible for Subrogation

Address

Street Address Address Line 2 City State ZIP Code

Phone

New Loss Information

Date of Loss

Loss Location

Adverse Party/Parties (if known)

Brief Description of Loss

Include names and contact information for any known witnesses.

Nature Of Injury

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Medical Benefits Paid

Indemnity Benefits Paid

Employer/Insured Information

Full Employer Name*

Contact Person

Phone

Address

Street Address Address Line 2 City State ZIP Code

Injured Worker's Information

First Name*

Last Name*

Spouse or Contact Person

Phone

Address

Street Address Address Line 2 City State ZIP Code

Third-Party Counsel Representing Injured Worker

Name of Attorney

Firm Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Workers’ Compensation Counsel Representing Injured Worker

Name of Attorney

Firm Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

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Important Notice Regarding Case Referral Submissions

Submitting 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.

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