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Event title

Please fill out the form below to refer a case to us. Or, download our fillable form, fill it out offline, and upload it afterward.

Case type

Hearing information

Type of Hearing
Date & Time

Case Information

Claim #*
Employee Name*
Date of Birth*
Policy Period*
Date of Injury*
Body Parts
Employee's Attorney
Application Filed On
Is the case admitted, denied, or on delay?
If denied, what was the denial date?
File Answer*
If the case is on delay, when is the decision date?*



Hanna Brophy Office
Hanna Brophy Attorney

Benefits paid


defense discovery requested

Depose Applicant*
Schedule Medical Exam*


File upload

You may attach a file of any of the following types to your request: pdf, doc, rtf, jpg, jpeg, gif, bmp, png, or tiff. File sizes are limited to 10MB. Please email the selected attorney for this file with any documents above 10 MB.

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