Legal Defense

Claim Number:*

Referral Source

Name:*

Email:*

Title:

Company:*

Phone:*

Ext:

Fax:*

Address:*

City:*

Province:*

Postal Code:*

Principle Insurer:

Claimant Information

Salutation:

First Name:*

Last Name:*

Address:*

City:*

Province:*

Postal Code:*

Home Phone:*

Other Phone:

Date Of Birth:


Date Of Injury:*


Legal Information

Legal representative?*

Injuries

Independent Examinations - Assessment Type

Other Specialty/Expertise

Do you require the report by a specific date?

Date:*


Other Options

Transportation:

Interpreter Required:

Language:

Special Instructions:

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