Legal Defense

    Claim Number:*

    Referral Source

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    Email:*

    Title:

    Company:*

    Phone:*

    Ext:

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    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?*

    Name:

    Title:

    Company:

    Phone:

    Fax:

    Address:

    City:

    Province:

    Postal Code:

    Injuries

    Independent Examinations - Assessment Type

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