Employer Referral Form

Claim Number
Date of Referral Day: Month: Year:

Referral Source - (Part 1/8)

Name
Email
Adjusters Name
Title
Company
Fax
Address
City
Province
Postal Code

Client Information - (Part 2/8)

Salutation
First Name
Last Name
Address
City
Province
Postal Code
Home Phone
Other Phone
Preferred Location for Assessment:
Preferred City:
Preferred Province:

Medical Information - (Part 3/8)

Injuries

Treating Physician
Address
City
Province
Postal Code
Phone
Fax

Legal Information - (Part 4/8)

Legal Representative
Title
Company
Phone
Fax
Address
City
Province
Postal Code

Employer Information - (Part 5/8)

Employer Name
Contact
Phone
Fax
Address
City
Province
Postal Code
Job Title/Occupation

Independent Examinations - Assessment Type - (Part 6/8)

 In-Home Assessment Job Site Analyses

Other Assessments - Please Specify

If "other," please explain:

Other Options - (Part 7/8)

Transportation
 Yes No To Be Determined

Interpreter Required
 Yes No

Language

Benefits Claimed

If "Other," Please Specify

Date Benefits Were Claimed:
Day: Month: Year:

Additional Questions

Final Employer's Comments