LifeWorks Legal Provider Form
The fields marked with an
*
below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at
Central.DB@Ceridian.com
or call our Provider Line at 800 290-4311, extension 5862. Leave your name and phone number and someone will return your call.
*
New Provider Information
Updated Provider Information
Provider Name
*
Phone
*
(
)
-
Main Contact
*
Address
*
City
*
State
*
AL
AK
AR
AZ
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MO
MS
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
Zip
*
Email Address
*
Provider Type
*
Private Legal Resources
Public Legal Resources
Please check off any of the following that apply:
Legal Services
Abuse
Adoption
Advocacy
Bankruptcy
Business
Child Support
Civil Rights
Collections
Consumer
Copyright
Criminal
Custody
Disability
Divorce
DWI / DUI
Elder
Employment
Estate & Probate
Family
Gay & Lesbian
General
Housing
Immigration
Insurance
Intellectual Property
International
Juvenile
Landlord
Lawyer Referral Service
Malpractice
Medicare / Medicaid
Patent
Personal Injury
Pro-bono
Real Estate
Sexual Harassment
Social Security
Tax
Tenant's Rights
Utilities
Victim Assistance
Welfare
Wills
Worker's Compensation
Other Languages Spoken
French
Spanish
Other:
Additional Information/Comments:
