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Resources
Express Referral
Contact Us
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DGC E-ReferHunter Hirsch2021-12-08T14:12:40-08:00

Online Form Referral

DGC ATTORNEY TO ASSIGN:

First Name:

Last Name:

GENERAL E-REFERRAL INFORMATION:

Claimant:

Date of Injury:

Insured:

WCAB No(s):

WCAB Venue:

Claim Number:

Insurance Company:

Policy No:

Coverage:

Hearing Scheduled:

Yes

No

Other

Date (if scheduled):

Time (if scheduled):

Hours

:

Minutes

AM/PM

Board (if scheduled):

Deposition Authorized:

Yes

No

Date of Employer Knowledge:

Date DWC-1 Given to Employee:

Date DWC-1 Returned to Employer:

TOTAL BENEFITS PAID TO DATE:

Medical Paid:

.

Temporary Disability Total:

.

Rate:

Period of Payments:

Issues:

Insurance Coverage

Injury AOE/COE

Earnings

Temporary Disability

Apportionment

Medical/Legal Liens

Further Treatment

Death Claim

Statute of Limitations

Subrogration

.

Employment

Parts of Body

Rate (TD/PD)

Permanent Disability

Fraud

Other Liens

Self-Procured Medical Treatment

Dependency

Prejudiced by Lack of Notice

Third Party Recovery Credit

Comments:

SUBMITTED BY:

Date:

First Name:(Required)

Last Name(Required)

Address:

Street Address: Address Line 2: City: State / Province / Region: Postal / Zip Code: Country:

Contact Number:(Required)

Email:(Required)

File

Drop files here or

Max. file size: 120 MB.

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Latest News

Hunter Hirsch2026-09-29T07:50:50-07:00

Dietz, Gilmor & Chazen is pleased to announce the promotion of H. Douglas Hawkins to firm Partner

Dietz, Gilmor & Chazen is pleased to announce the promotion of H. Douglas Hawkins, to [...]

Hunter Hirsch2026-05-14T15:20:51-07:00

Dietz, Gilmor & Chazen Announces Promotion of Carolyn Bell to Chief Operating Officer

Carolyn Bell, Chief Operating Officer Dietz, Gilmor & Chazen Professional Corporation is pleased [...]

Our Firm

Established more than 20 years ago, our California workers’ comp law firm is committed to providing the highest level of legal services and delivering optimal results.

With offices strategically located in San Diego, the Inland Empire, greater Los Angeles, the Bay Area, Long Beach, Sacramento, Santa Monica, Orange County and Fresno/Central California, our experienced attorneys are readily accessible to focus on your needs.

Dietz, Gilmor & Chazen is noted for its integrity, problem solving and assertive legal representation.

DGC Locations

San Diego/ Corporate Office
Ontario/Inland Empire
Greater Los Angeles Area
San Francisco/Bay Area
Long Beach
Sacramento
Santa Monica
Orange County
Fresno/Central California

Latest News

Dietz, Gilmor & Chazen is pleased to announce the promotion of H. Douglas Hawkins to firm Partner September 29, 2026
Dietz, Gilmor & Chazen Announces Promotion of Carolyn Bell to Chief Operating Officer May 14, 2026
Dietz, Gilmor & Chazen is pleased to announce the promotion of Peter M. Golden, Esq., to firm Partner November 1, 2025
Dietz, Gilmor & Chazen is pleased to announce the promotion of Christopher J. Vincent, Esq., to firm Partner June 1, 2025
Dietz, Gilmor & Chazen is pleased to announce the promotion of Brandon Thorson, Esq., to firm Partner April 1, 2025

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