Request for Service Form Field Case Management
*Indicates Required Field
*Service Request:

New File

Reopen File

Matrix File



Field Case Management

Telephonic Case Management

One Task Assignment

Initial/One-Shot Assignment

Cost Projection

Lifetime Cost Projection
       
Claimant Information:
*Name
Mailing Address
City
State
Zip Code
*Phone Number   Cell Phone Number
Social Security Number
*Birth Date
Contact Person
Contact Phone Number
Contact Mailing Address
City
State
Zip Code
Contact Phone Number   Cell Phone Number
Employer Information (if Workers' Compensation Claim):
*Name
*Contact Person
*Contact Phone Number
Mailing Address
City
State
Zip Code
Occupation   Salary
Carrier Information:
Referred By (name)
*Date
Adjuster
*Carrier
Mailing Address
City
State
Zip Code
*Phone Number
Fax Number
*Type of Coverage
Workers' Compensation
Disability 		Health
General Liability

Auto Liability B.I.
Home Owners

Auto No-Fault
Other
   
Insured
*Policy Limit: $
(if Auto or Home Owners Claim )
Deductible: $
Accident Information:
*Date of Loss
Claim Number
Diagnosis
Physician(s)
Hospital(s)
(if applicable)
Contact Phone or Beeper Number (if applicable)
*Attorney Name
(if applicable)
Firm Name
Mailing Address
City
State
Zip Code
*Phone Number
*Instructions/Other pertinent data