Class Action Informational Form

Welcome:

Class Action Informational Form

IMPORTANT: If you have already completed this form once,

please do not submit another. If you must update and/or make

a change, please contact us using this form: Contact Us. Thank you.

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For readability, please do not type in ALL CAPS.

First Name:

Middle: Last:

Street Address:

Apt. No.:

City:

State: Zip:

Home Phone:

Cell Phone:

Email Address: (very important)

Employer (at time of injury):

Insurance Carrier:

Date(s) of Injury(ies):

WCAB Claim Title: (If known, for example, Joe Brown vs. XYZ Corporation)

WCAB Case No.: (It is very important to give the WCAB number and not the claim number)

If you are/were represented by an attorney, please check this box: (Leave blank if not represented by an attorney)

Comments (Injured body parts, date case closed, C&R, Stipulation, etc.): For readability, please do not type in ALL CAPS.

If you utilize a list of approved senders or other
means (such as rules), you must add
Kazandjieff & Traney LLP
to the list and/or be accepted, otherwise our email
responding to your inquiry will not be allowed.

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