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Employer Referral Form
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Referral Form (Lawyer)
Home
Date
Claimant Information
Claimant Information
Mr.
Mrs.
Miss
Ms.
Name
Address
Date of Birth
Date of Loss
Telephone
Fax
Reported Injuries
Legal Representative
Legal Firm
Lawyer
File Number
Address
Telephone
Fax
Email address
*
Insurer Information
Insurance Company
Referring Company
Adjuster
Claim/Policy #
Address
Telephone
Fax
Email address
*
Examination Type
Accident Benefits
S.44
LAT
Tort
Defence
Plantiff
Medical Malpractice
Life
Disability - STD/LTD
Disability (other)
Examination(s) Required
Orthopaedic
Neurological
Ergonomic Assessment
Physiatry
Neuro-psychological
Functional Abilities Evaluation
Psychological
In-Home Occupational Therapy
Future Care Cost Analysis
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
Additional Services
Transportation
Yes
No
Interpreter Required
Yes
No
Language
