Claims Examiners' Case Management Request Form:

  • Use the Tab key to navigate through the form:
  • 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:
Department:
Date of Hire:
Birth date: SSN:
Injury date: If injury date is not relevant, enter: 01/01/1900
Gender: M  F

LDW

TD Rate:

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

Modified Work Available? Y  N
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: 44.220.62.183
 
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
Physician Within Network? Y  N
Date:
Work Restrictions:
Case Details:
Telephonic
Full Field Assignment
One-Time Task Field Assignment
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If you are uploading documents to the referral form, you must click 'Upload Files' BEFORE submitting your request. Make sure to attach all files prior to clicking "Upload Files". Thank you!