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Part 1 of 6

This case is*:

Routine

Rush

If this is a rush, when is it needed?

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. Use Control, Alt or Shift to select more than one.

	Medical/Psychiatric		Death Certificate
	Employment/Personnel		Coroner's Report
	Police Report

Transcribe Recorded Interviews
(Transcription charges apply)

Yes

Public Records Research
If applicable, use Control, Alt or Shift to select more than one.

	Courts		DMV
	Employment		WCAB/Edex
	Other (please explain		Police

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