Referral Form

Today’s Date:

Due Date:

Your Contact Name:

Company:

Program Code:

Address:

City:

State:

Zip:

Email:

Telephone:

Fax:

Defense Attorney:

L/O Name:

Address:

City:

State:

Zip:

Telephone:

Fax:

WCAB No:

Insured/Employer:

Address:

Contact:

Telephone:

Fax:

May we contact?

Claimant/Subject:

Claim No:

Address:

City:

State:

Zip:

Telephone:

Addl. Info:

SSN:

DOB:

CDL:

Sex:

Race:

Ht:

Wt:

Hair Color/Style:

Addl. Info:

Occupation:

DOH:

DOI:

LDW:

RTW:

Injury:

Limitations:

Claimant Working at Insured Y/N?

On Modified Duty Y/N?

If Claimant TTD, till when?

90 Day Delay Date is:

Surveillance

AOE/COESubrogationLiabilityMedical CanvassSocial Media InvestigationBackground CheckSIU/FraudOther

Special Instructions:

Please upload file:

Referral Form

Type of Service:

Interview

Secure

<img decoding="async" src="https://sp-ao.shortpixel.ai/client/to_auto,q_glossy,ret_img/https://www.arguswest.com/wp-content/themes/arguswest-theme/img/logo-title.png" alt="logo"> Referral Form

Type of Service:

Interview

Secure

Referral Form