Claims Examiners' Return-to-Work / Ergonomics:

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  • Please enter all dates like: mm/dd/yyyy
  • Items in Red must be entered.
PDF Form
Injured Employee:
First Name:
MI
 Last
Address:
City: State: Zip:
Phone:
Primary Language:
Occupation:
Birth date: SSN:
Injury date:
If injury date is not relevant, enter: 01/01/1900 		Gender: M  F
LDW

 Employer:
Company:
Address:
City: State: Zip:
Phone: Fax:
Email:
Contact:

Defense Attorney:
Same as last referral
First Name: Last Name:
Firm Name:
Address:
City: State: Zip:
Phone: Fax:
Email:

Service Requested:
Please Choose Requested Services:
Use the control key to choose more than one:

Assigned to:
Additional Comments:

Claims Examiner:
Save My Information For Future Requests
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Same as last referral
First Name: Last Name:
Company:  
Address:
City: State: Zip:
Phone: Ext: Fax:
Email:
Claim #:  
If claim number is not relevant, enter: 0000
Your Internet Address: 3.15.221.67
 
Applicant's Attorney:
Same as last referral
First Name: Last Name:
Firm Name:
Address:
City: State: Zip:
Phone: Fax:
Email:
Authorization obtained from applicants attorney? Y  N
Not litigated
Physician:
First Name: Last Name:
PH Degree: Med Group:
Address:
City: State: Zip:
Phone: Fax:
Email:
Diagnosis:
Permanent and Stationary? Y  N
Date:
Work Restrictions:
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