Referral Form

Step 2 of 7 · Injured Worker
Injured Worker / Plaintiff

A fuller picture here means we're ready to move the moment we accept the case.
Name is required. The more you add now, the sooner we can get to work — share what you have, and we'll follow up on anything missing.
Injured Worker / Plaintiff Name

First NameLast Name
Contact Information — optional
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Case Details — optional
Date of Birth

MonthDayYear
Date
Date of Injury

MonthDayYear
Date
Claim / WCAB #
Occupation
Language
Gender
Interpreter Needed?
Injured Body Parts
- Employer Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Contact Person
- Email
  example@example.com

Step 3 of 7 · Referring Party
Who's referring this case?

Tell us who to contact about this referral. Required fields are marked; everything else helps us prepare.
Who is referring this case?
Applicant / Plaintiff Attorney
Attorney Name
Law firm
Attorney Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Point of Contact — if different from the attorney
Contact Name
Contact Email
example@example.com
Position
Defense Attorney
Attorney Name
Law firm
Attorney Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Point of Contact — if different from the attorney
Contact Name
Contact Email
example@example.com
Position
Claims Specialist
Name
Company
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Claim #
Date Referred

MonthDayYear
Date
Point of Contact — if different from the specialist above
Contact Name
Contact Email
example@example.com
Position

Step 4 of 7 · Other Parties
Who else is on this case?

Share what you have on the other parties — we'll follow up on anything missing.
Do you have contact info for the Applicant / Plaintiff Attorney?
Attorney Name
Law firm
Attorney Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Point of Contact — if different from the attorney
Contact Name
Contact Email
example@example.com
Position
Do you have contact info for the Defense Attorney?
Attorney Name
Law firm
Attorney Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Point of Contact — if different from the attorney
Contact Name
Contact Email
example@example.com
Position
Do you have contact info for the Claims Specialist?
Name
Company
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Address
City / State / Zip
Claim #
Date Referred

MonthDayYear
Date
Point of Contact — if different from the specialist above
Contact Name
Contact Email
example@example.com
Position

Step 5 of 7 · Case Documents & Details

Upload what's ready now — for anything outstanding, we'll send a secure link so you can add it later.
Permanent Disability Rating
if you have the number
Case Documents

The sooner we have these, the sooner we can schedule and begin. Check what you're sending and upload anything ready now — we'll request the rest after we accept.
What can you send now? (check what applies)

Other
Upload Demographic sheet (or leave blank — we'll send a link)

Cancelof
Upload Permanent Disability report (or leave blank — we'll send a link)

Cancelof
Upload Medical reports (or leave blank — we'll send a link)

Cancelof
Which reports are these? (optional)
Upload document (or leave blank — we'll send a link)

Cancelof
For anything you don't upload now, we'll send a secure link so you can add it whenever it's ready.
Comments or Special Instructions

Step 6 of 7 · Retainer & Fee

We handle this so it never holds up your referral.
Is a signed retainer already on file with VCO Vocational Specialists?
Firm or attorney the retainer is under (so we can match it)
Who should sign the retainer?

We'll email the retainer for e-signature right after you submit — the referral goes through now either way
Signer Name
Signer Email
example@example.com
Position
Retainer Fee
How would you like to handle the retainer fee? (optional)

Product Name

$10.00 Quantity

Total

Review & Submit

Take a quick look, then submit — you'll get instant confirmation.
Should be Empty:

Step 1 of 7 · Referral & Services