Express Referral – Support Claim Services

SUBMIT EXPRESS REFERRAL

If you are interested in sending us a referral, please complete the form below:
(* = required fields)

Claim Information

Claimant First Name(Required)

Claimant Middle Name

Claimant Last Name(Required)

Address

Address Line 1 Address Line 2 City State Zipcode

Claimant Phone

Adjuster Phone

Adjuster E-Mail(Required)

Adjuster Name

Accepted Body Parts

Insured/Company Name

Insured Middle Name

Insured Last Name

Attorney Information

(If Represented)

Attorney Name

Attorney Address

Address Line 1 Address Line 2 City State Zipcode

Referral Type

(Select referral type)

Insurance Company(Required)

Type 1(Required)

Type 2(Required)

Specialties

(Please select at least one specialty)

Specialties(Required)

Other Specialty(Required)

Claimant Details

Date of Incident(Required)

Policy Number

Claim Number(Required)

Social Security

WCB#

Date Loss Reported

Date of Birth(Required)

Medical Records

Request file for medical records

No medical records available at this time

Request Details

(Select All That Apply)

Request Details

Attending Physician

(Fill All That Apply)

Physician Name

Physician Specialty

Physician Address

Address Line 1 Address Line 2 City State Zipcode

Add cc For Notifications

(Fill All That Apply)

CC1

CC2

CC3

Special Instructions

(Fill All That Apply)

Special Instruction

Transportation

Early IME

Translation

Attorney File #

Comments

Relevant Files

Drop files here or

Accepted file types: gif, jpeg, png, bmp, doc, docx, pdf, txt, Max. file size: 8 MB, Max. files: 10.