Workers’ Compensation Client Forms

Please click on the links below to access forms you may need throughout the workers’ compensation claims process. Contact Leep, Tescher, Helfman and Zanze‘s Redding-based team to schedule a free initial consultation by calling (530) 287-6674 or filling out the online contact form. Attorney Ben Helfman works with injured workers across Shasta County and all surrounding Northern California counties.

Forms:

Application for Adjudication of Claim
Declaration of Readiness
Potential Client Questionnaire
QME (Qualified Medical Evaluator) request form
Medical Mileage Expense Forms

Call For A Free Consultation!

(530) 287-6674

Subscribe To Our Newsletter

Please provide your name and email address to subscribe to our monthly newsletter.

"*" indicates required fields

* Making a false or fraudulent workers' compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.