Name of Insurer:
Date of Referral
Claim Number:
Adjuster Responsible for Subrogation:
Address:
Phone Number:
Fax Number:
E-mail:
Adjuster Responsible for Workers' Comp:
Date of Loss*
Loss Location:
Brief Description of Loss:*
If available, please send the Employer's First Report of Injury and all investigative materials
Company Name:
Contact Person:
Name:
Spouse or Contact Person:
AWW:
Comp. Rate:
Medical Bills Paid to Date $:
Medical Bills Incurred $:
Indemnity Payments Paid to Date $:
Indemnity Payments Incurred $:
Brief Description of Injury Sustained:*
Telephone Number:
Representing the Injured Worker for: