Refer A Case

We are ready to take your case.

We’ve provided case referral forms to help jumpstart the process. You are also welcome to submit a referral through your current preferred process. (Fields marked with an asterisk * are required)

*Contact Email: A confirm email will be sent to this address

Referral Date:

Claimant Name:

*Claim Number:

Adjuster Name:

Adjuster Email Address:

Adjuster Phone:

Adjuster Fax:

Employer:

WCAB Number:

Insurer:

D.O.I.:

Settlement Type/Amount:

Upcoming Lien Conference/Trial:

Defense Attorney (with contact info):

PTP (Primary Treating Physician):

Instructions to AM Lien Solutions

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Refer A Case

We are ready to take your case.

*Referral Type

Clients & Visitors

Refer A Case

We are ready to take your case.

*Referral Type

Clients & Visitors

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