Auto Work Comp Referrals

Please select the type of referral *

Insurance Information

Adjustor Name *

First

Last

Phone *

Email *

Fax

Claim Information

Claim # *

Is Auto is Primary? *

Yes
No

Primary Insurance Name *

Name of Insured

First

Last

Insurance ID #

Group ID #

Does claim have unlimited benefits? *

Yes
No

Amount that claims are capped at or maximum benefit amount? *

Claimant Information

Name *

First

Last

D.O.B *

Date of Injury *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Type *

Cell
Home
Work

2nd Phone

Type

Cell
Home
Work

Alternate Contact Name

First

Last

Alternate Contact Phone

Alternate Contact Relation

Additional Claim Information

Diagnoses *

Claimant is currently at *

ICD-10 Code

Special instructions or notations

Upload Medical Files

Click or drag a file to this area to upload.

Auto/Work Comp Referrals

Insurance Information

Company Information

Claim Information

Claimant Information

Additional Claim Information