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SUBMIT CASE

PLEASE SUBMIT AS MUCH INFORMATION AS POSSIBLE FROM THE LIST BELOW

CLIENT INFORMATION:

  • CLIENT
  • CLAIM NUMBER
  • CLIENT CONTACT (Name, Location, email)
  • AMOUNT OF DAYS (If SV)
  • CASE TYPE (WC, Auto, Domestic, Etc.)
  • CASE SERVICE (eDossier, SV, HC, Etc.)

 

CLAIMANT INFORMATION:

  • FULL NAME
  • ALIAS
  • ADDRESS
  • DATE OF BIRTH
  • SOCIAL SECURITY NUMBER
  • PHONE NUMBER
  • SEX AND RACE
  • PHYSICAL DESCRIPTION
  • MARITAL STATUS
  • DEPENDENTS

 

  • DATE OF INCIDENT
  • DRIVER’S LICENCE INFO
  • INJURY / LIMITATIONS
  • EMPLOYER INFO
  • ATTORNEY INFO
  • VEHICLE INFO
  • IME / APPOINTMENT/ HEARING (Date, Time, Location)

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