a:9:{s:6:"active";b:1;s:7:"subject";s:74:"[cla-name]: Manley & Associates "Case Management Referral" Form Submission";s:6:"sender";s:47:"[your-name] <wordpress@manleyandassociates.com>";s:9:"recipient";s:130:"lawatson@manleyandassociates.com, nformisano@bmanleymsa.com, cmreferral@manleyandassociates.com, takamatsu@manleyandassociates.com";s:4:"body";s:1993:"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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