Referrals Form

Referral Date:
Claim Type:
Benefit (s) to be Addressed:
Other
Type of Assessment:
Other

Claimant/Employee Information

Salutation
Date of Birth:
First Name
Last Name
Claim Number
Policy Number
Date of Loss
Job Title
Address
City
Province
Postal Code
Telephone
Cell Phone
Fax
Email

Referral Source

Company Name
Referral Contact Name:
Address
City
Province
Postal Code
Telephone
Fax
Email

Insurance Company Information

Name of Insurance Company
Adjuster Name
Address
City
Province
Postal Code
Telephone
Fax
Email
Insured’s Name
Policy Number

Employer Information

Company Name
Address
City
Province
Postal Code
Telephone
Fax
Email
Occupation

Legal Representative

Name of Firm
Name of Lawyer/Paralegal
Address
City
Province
Postal Code
Telephone
Fax
Email

Additional Services Needed to be Arranged

Name of Firm
Name of Lawyer/Paralegal
Address
Interpreter YesNo
Language
TransportationYesNo
Pickup Address:
Special Accommodations Required