FEDERAL WORKERS’ COMPENSATION REFERRAL FORM

For medical providers referring injured federal employees for educational/legal intake review. Submission of this form does not create an attorney-client relationship.

Referring Provider Name

Injured Worker First name

Injured Worker Last name

Injured Worker Phone Number

Injured Worker Email

Is the injured worker a federal employee?

Has the injured worker consented to being contacted by Gunn Law Firm, PLLC?

No

Yes

Is the Injured Worker suffering from a medical condition, illness or injury?

Injury

Illness

Other Medical Condition

What is the injury?

On what date was the federal worker injured?

Additional Details