Submit a Case to Popilock Law

Are you a Workers’ Compensation insurance company representative who wants assistance investigating a workplace accident, or needs legal advice for protecting your workers’ compensation lien? Or are you the victim of a workplace incident who needs legal representation that goes above and beyond what typical Workers’ Comp attorneys deliver? Submit your case to Popilock Law below.

Name of Insurer(Required)

Date of Referral(Required)

Claim Number(Required)

Adjuster Responsible for Subrogation(Required)

Address

Phone

Fax Number

New Loss Information:

Date of Loss

Loss Location

Brief Description of Loss

Include names and contact information for any known witnessess.

Employer/Insured Information:

Company Name(Required)

Contact Person

Phone

Address

Injured Worker's Information:

Name(Required)

First Last

Spouse or Contact Person

Phone

Address

AWW

Comp. Rate

Medical Bills Paid to Date ($)

Medical Bills Incurred ($)

Indemnity Payments Paid to Date ($)

Indemnity Payments Incurred ($)

Brief Description of Injury Sustained(Required)

Injured Worker's Attorney's Information:

Attorney Name

Attorney Phone

Attorney Address

Representing the Injured Worker for:

Workers’ Comp

Third Party

File Upload(s)

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