Submit a new Workman's Compensation Referral


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To submit a new Worker's Compensation Referral

Fill in all pertinent fields (Amber background indicates required)
and click "Submit WC Referral" at the bottom




Claimant Information - CaseID:
First Name ......Last Name ......
SS Number ......Date of Birth ...
Email Addr .....Phone ..............
Addr 1 .............Addr 2 .............
City ..................State: ...............
Zip Code .........Country ...........
Employer
 
Referral Information
Referrer Name
Referring Organization
Referrer Email
Referrer Phone
 
Defense Counsel Name
Defense Counsel Organization
Defense Counsel Email
Defense Counsel Phone
 
Plaintiff Counsel Name
Plaintiff Counsel Organization
Plaintiff Counsel Email
Plaintiff Counsel Phone
 
Insurer Name
Insuring Organization
Insurer Email
Insurer Phone
 
Broker Name
Broker Organization
Broker Email
Broker Phone
 
Name of person submitting form
 
Case Details
Claim Number: Date of Accident:
Jurisdiction: WCB Number (if NYS):
Service Request:
 
Injury(s) Alleged - Please describe (use ICD9 Codes if available)
 
Injury(s) Denied or Controverted (If any, please describe):
 
If there is a pending settlement offer or demand, what is the approximate value?
 
Update Details