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Please fill out the new assignment submission form. We will respond to your request as soon as possible.

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Your Name:  
Your Email Address:  
Part 1 of 6  
Deadline  
Claim Number  
Client/Company Name*  
Person's Name Completing Form*  
Title  
Client Email*  
Phone Number*  
Fax  
Case Title  
Date of Injury (Complaint)  
LDW  
RTW  
Part 2 of 6: Claimant, Applicant or Complainant Info    
Name*  
This person is the*  
Street Address  
City  
State  
Zip  
Country  
Phone Number  
Date of Birth  
Social Security Number  
Date of Hire  
Occupation/Title  
Part 3 of 6: Employer or Insured  Info    
This party is the*  
Name of Party*  
Street Address  
City  
State  
Zip  
Country  
Phone Number  
Contact Name  
This person is the  
Contact Phone  
Part 4 of 6: Other Parties involved (Applicant Attorney, Witness, Respondent, etc)    
Name  
Street Address  
City  
State  
Zip  
Country  
Contact Phone  
Part 5 of 6: Incident Info and/or Conflict Issues    
Exam Date  
Deposition/Trial Date  
Statutory Deadline  
Complaint/Claim Facts*  
Instructions  
Part 6 of 6: Records and Releases    
Get Signed Releases
Click more than one if applicable.		  
Medical    Psychiatric    Employment
If records need to be obtained, select all those that apply.  
Medical/Psychiatric Death Certificate
Employment/Personnel    Coroner's Report
Police Report
Transcribe Recorded Interviews
(Transcription charges apply)		  
Yes   
No
Public Records Research
  
Courts    DMV
Employment    WCAB/Edex
Other Police
 Security Image
Image Security Code*