make a referral

true end-to-end engagement starts here

Our simplified referral process makes it as easy as possible to get going. We just need a little information from you first.

I am requesting the following service *

Claim Number 1: [Primary, TPA] *

Claim Number 2 (if applicable): [Carrier, Excess]

Claimant’s Last Name *

Claimant’s First Name *

Claimant’s Date of Birth *

Claimant’s Date of Injury *

Jurisdiction *

Employer

Name *

Company *

Email *

Phone *

What is the goal of this referral? Any special instructions?

Name

Company

Phone

Would you like to add an attorney?

Yes