<h3 class="heading3">CLAIMANT</h3>

[text* your-name class:suba placeholder "FULL NAME"]

DOB: [date your-birth class:suba placeholder "BIRTH DATE"]

SSN: [text your-ssn class:digits placeholder "SSN"]

<p>SEX: </p>
[select gender class:suba "Male" "Female"]

[email your-email class:suba placeholder "EMAIL ADDRESS"]

[text your-carrierf class:suba placeholder "CARRIER FILE NO."]

[text your-street class:suba placeholder "STREET"]

[text your-city class:suba placeholder "CITY"]


[select your-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number your-zip min:5 class:sub placeholder "ZIP CODE"]

[text date-in class:suba placeholder "DATE OF INJURY"]

[text file-type class:suba placeholder "FILE TYPE"]

<p>WC </p>

[select Iamthe4 class:suba "YES" "NO"]

<p>OCCUPATIONAL</p>

[select Iamthe3 class:suba "YES" "NO"]


<p>LONGSHORE</p>

[select Iamthe1 class:suba "YES" "NO"]

<p>VOCATIONAL</p>

[select Iamthe2 class:suba "YES" "NO"]


[textarea your-notes class:suba placeholder "NOTES"]

[textarea list-body1 class:suba placeholder "Non-related work injury/condition: "]

[textarea list-body2 class:suba placeholder "Description of work injury: "]


[textarea list-body3 class:suba placeholder "Other Comments: "]

[number your-phone class:digits placeholder "PHONE NUMBER"]

[text your-employ class:suba placeholder "EMPLOYER NAME"]



<h3 class="heading3">CLAIMANT ATTORNEY </h3>
[text cla-name class:suba placeholder "CLAIMANT ATTORNEY NAME"]
[text cla-street class:suba placeholder "CLAIMANT ATTORNEY STREET"]
[text cla-city class:suba placeholder "CLAIMANT ATTORNEY CITY"]
[select cla-satate class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]


[number cla-zip min:5 class:sub placeholder "CLAIMANT ATTORNEY ZIP CODE"]
[email cla-email class:suba placeholder "CLAIMANT ATTORNEY EMAIL ADDRESS"]
[number cla-phone class:digits placeholder "CLAIMANT ATTORNEY PHONE NUMBER"]
[number cla-fax class:suba placeholder "CLAIMANT ATTORNEY FAX NUMBER"]

<h3 class="heading3">ADJUSTOR</h3>
[text adjustor-name class:suba placeholder "ADJUSTOR NAME"]
[text adjustor-tpa class:suba placeholder "CARRIER/TPA/SERVICING AGENT"]
[text adjustor-street class:suba placeholder "ADJUSTOR STREET"]
[text adjustor-add class:suba placeholder "ADJUSTOR ADDRESSS"]
[text adjustor-city class:suba placeholder "ADJUSTOR CITY"]

[select adjustor-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number adjustor-zip min:5 class:sub placeholder "ADJUSTOR ZIP CODE"]
[email adjustor-email class:suba placeholder "ADJUSTOR EMAIL ADDRESS"]
[number adjustor-phone class:digits placeholder "ADJUSTOR PHONE NUMBER"]
[number adjustor-fax class:suba placeholder "ADJUSTOR FAX NUMBER"]

<h3 class="heading3">DEFENSE ATTORNEY</h3>

[text deffenseattorney-name class:suba placeholder "DEFENSE ATTORNEY NAME"]
[text deffenseattorney-firm class:suba placeholder "DEFENSE ATTORNEY FIRM"]
[text deffenseattorney-street class:suba placeholder "STREET"]
[text deffenseattorney-city class:suba placeholder "DEFENSE ATTORNEY CITY"]

[select deffenseattorney-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number deffenseattorney-zip min:5 class:sub placeholder "DEFENSE ATTORNEY ZIP CODE"]
[email deffenseattorney-email class:suba placeholder "DEFENSE ATTORNEY EMAIL ADDRESS"]
[number deffenseattorney-phone class:digits placeholder "DEFENSE ATTORNEY PHONE NUMBER"]
[number deffenseattorney-fax class:suba placeholder "DEFENSE ATTORNEY FAX NUMBER"]



[submit class:btn-submit "SUBMIT"]
1
[cla-name]: Manley & Associates "Case Management Referral" Form Submission
[your-name] <wordpress@manleyandassociates.com>
lawatson@manleyandassociates.com, nformisano@bmanleymsa.com, cmreferral@manleyandassociates.com, takamatsu@manleyandassociates.com
From: [your-name] <[your-email]>

FORM TYPE: Case Management Referral

<h3 class="heading3">CLAIMANT :</h3>

Your Name: 
[your-name]

Date Of Birth:
[your-birth]

SSN:
[your-ssn]

sex:
[gender]

Email-Address:
[your-email]

Carrier File No.:
[your-carrierf]

Street:
[your-street]

City:
[your-city]

State:
[your-state]

ZIP:
[your-zip]

Date Of Injury:
[date-in]

File Type :
[file-type]

WC:
[Iamthe4]

OCCUPATIONAL:
[Iamthe3]

LONGSHORE:
[Iamthe1]

VOCATIONAL:
[Iamthe2]

Notes:
[your-notes]

Non-related work injury/condition:
[list-body1]

Description of work injury:
[list-body2]

Other Comments:
[list-body3]

Phone Number: 
[your-phone]

Employer Name:
[your-employ]


<h3 class="heading3">CLAIMANT ATTORNEY </h3>

Claimant Attorney Name:
[cla-name]

Claimant Attorney Street:
[cla-street]

Claimant Attorney City:
[cla-city]

Claimant Attorney State:
[cla-satate]

Claimant Attorney Zip:
[cla-zip]

Claimant Attorney Email:
[cla-email]

Claimant Attorney Phone:
[cla-phone]

Claimant Attorney Fax:
[cla-fax]

<h3 class="heading3">ADJUSTOR</h3>

Adjuster Name:
[adjustor-name]

Carrier/TPA/Servicing Agent:
[adjustor-tpa]

Adjuster Street:
[adjustor-street]

Adjuster Address:
[adjustor-add]

Adjuster City:
[adjustor-city]

Adjuster State:
[adjustor-state]

Adjuster Zip:
[adjustor-zip]

Adjuster Email:
[adjustor-email]

Adjuster Phone:
[adjustor-phone]

Adjuster Fax:
[adjustor-fax]

<h3 class="heading3">DEFENSE ATTORNEY</h3>

Defense Attorney Name:
[deffenseattorney-name]

Defense Attorney Firm Name:
[deffenseattorney-firm]

Defense Attorney Street:
[deffenseattorney-street]

Defense Attorney City:
[deffenseattorney-city]

Defense Attorney State:
[deffenseattorney-state]

Defense Attorney Zip:
[deffenseattorney-zip]

Defense Attorney Email:
[deffenseattorney-email]

Defense Attorney Phone:
[deffenseattorney-phone]

Defense Attorney Fax:
[deffenseattorney-fax]


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This e-mail was sent from a contact form on Manley & Associates
(https://manleyandassociates.com/contact/)


1


Manly & Associate "[your-subject]"
Manly & Associate <wordpress@demo.likeconception.com>
[your-email]
Message Body:
[your-message]

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This e-mail was sent from a contact form on Manly &amp; Associate (http://demo.likeconception.com/like)
Reply-To: likeconceptioninfo@gmail.com



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