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Employer Referral Form
Insurer Referral Form
Lawyer Referral Form
IME
Plus
Referral Form (Insurer)
Home
Date
of Referral
Claimant Information
Claimant Information
Mr.
Mrs.
Miss
Ms.
Name
Address
Date of Birth
Date of Loss
Telephone
Fax
Reported Injuries
Insurer Information
Insurance Company
Referring Company
Adjuster
Claim/Policy #
Address
Telephone
Fax
Email address
*
Legal Representative
Legal Firm
Lawyer
File Number
Address
Telephone
Fax
Examination Type
Accident Benefits
S.44
Tort
Defence
LAT
Life
Disability - STD/LTD
Disability (other)
Examination(s) Required
Orthopaedic
Neurological
Return to Work
Physiatry
Neuro-psychological
Functional Abilities Evaluation
Psychological
In-Home Occupational Therapy
Home Modifications
Psychiatric
Job Site Analysis
Other (Specify)
Benefits to be Assessed
Income Replacement Benefits
Housekeeping/Home Maintenance
Long-term Disability (LTD)
Post 104 weeks
Attendant Care – Form 1
Caregiver Benefits
Catastrophic Impairment
Non-Earner Benefits
Medical and Rehabilitation Benefits
Applicable Forms
Treatment and Assessment Plan (OCF-18)
Amount (Specify)
Direct Assessment
Paper review
Transportation
Yes
No
Interpreter Required
Yes
No
Language