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      Detailed Form


      Subject
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      Referral Source

      Company
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      Claimant

      Claimant Name
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      Date of birth
      Home Phone
      Cell Phone
      Change of Definition/Date of loss
      Claim / Policy / File Number
      Translator
      Transportation
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      Any Occupation Means test

      Legal Representative (If Applicable)

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      Services Requested (select at least one service)

      Independent Medical Evaluation(IME)
      Medical Specialty
      Functional Capacity EvaluationCognitive Demands AnalysisPhysical Demands AnalysisJob Site AnalysisErgonomic AssessmentVocational EvaluationTransferrable Skills AnalysisLabour Market Survey
      Other - please specify
      Vocational Case Management1 Point Assessment2 Point Assessment3 Point Assessment
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      Additional Information

      Please fill in and send to info@rei-ime.com

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      1370 Don Mills Road, Suite 300 | Toronto | ON | M3B 3N7
      Phone 416-491-7100
      Fax 416-491-994

      Toll-Free:
      Phone 1-877-381-7200
      Fax 1-877-381-7200
      Mon-Fri: 8:30AM - 5:00PM Eastern Standard Time (EST)

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