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Requested By

TPA/Insurance Co.*:
Adjuster Name*:
Phone*:
Email*:
Phone (Direct):
Fax:

Additional Information

Case Type:
Classification*:  Nonsubscriber Work Comp
State Jurisdiction:
Special Instructions:

Employer Information

Name*:
Contact Name*:
Address 1:
Address 2:
City:   State  Zip
Phone:
Fax:
Email:

Employee Information

Name*:
Phone*:
Date of Birth*:
Body Part*:
Email:
Claim Number:
Address 1:
Address 2:
City:   State  Zip
Occupation:
SSN:
Date of Hire:
Date of Injury:
Accident Description:
Diagnosis:

Physician

Name:
Phone:
Address 1:
Address 2:
City:   State  Zip
Fax:

Attachment

Please attach the First Report of Injury (if available). This will help us process your case more efficiently. File type must be TIFF, PDF, Word or Excel. Max. Size 2MB.

Or you may fax the First Report of Injury directly to our Referral Fax # 888.225.9087

Attach Report:

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