Online Referral Form

** An email will be sent as confirmation. If you do not receive a reply from us within 24 hours, please call us at 800.772.8914. You are important to us. **

Client Information

* indicates required fields. Please make sure all six are filled in:

  • *Injured Worker/Client's Name
  • *Nature/Extent of Injury
  • *Adjuster
  • *Carrier
  • *Adjuster's Telephone Number
  • *Adjuster's Email Address

Before clicking the submit button, you will also need to enter the code at the bottom of the form in the space provided underneath the code.

*Injured Worker/Client: (required)

Address 1:

Address 2:

City:

State:

Zip Code:

Telephone:

Client's Social Security Number:

Client's Date of Birth:

Date of Injury:

*Nature/Extent of Injury: (required)

 

Adjuster/Carrier Information

Carrier File Number:

IC File Number:

*Adjuster: (required)

*Carrier: (required)

Address 1:

Address 2:

City:

State:

Zip Code:

*Adjuster's Telephone: (required)

Adjuster's Fax:

*Adjuster's Email: (required)

Referral Type:

Case Type:

Jurisdiction:

 

Employer Information

Employer:

Address 1:

Address 2:

City:

State:

Zip Code:

Contact:

Telephone:

Occupation:

Length of Employment:

 

Physician's Information

 
Physician Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Telephone:

Fax:

 

Plaintiff's Attorney Information

Attorney Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Telephone:

Fax:

Email:

 

Defense Attorney Information

Attorney Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Telephone:

Fax:

Email:

 

Other Contact Information

Nature of Contact:

Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Telephone:

Fax:

Email:

If, after clicking submit, you do not get a message stating that the form was successfully sent, please review the form to make sure the red *required fields are filled in.

Thank You