Referral Form

Please fill in the online form below to start the referral process. Fields with an asterisk * are required.

Transition2Work (nonprofit placement for Workers' Compensation claims)Disability (nonprofit placement for non-occupational disabilities)

Referring Party

Street Address:
Carrier/TPAEmployerNurse Case ManagerBrokerOther

Injured Worker and Claim Information

Street Address:
Usual Work Schedule:
Primary Language:
Secondary Language (if applicable):
Description of injury:
Rate of pay while in program:
Hours per week while in program:
Physical Restrictions:
Additional Information & Special Instructions:

Employer Contact Information

Street Address:
If part of a Self Insured Group or Captive Group, please list:

Carrier Information (Please provide if different than referring party listed above)

Same as Referring Party? YesNo
Company Name:

Claims Professional Contact Information


Litigation

Is the claim litigated?

If yes, please complete the following fields:

Defense Attorney Contact Information

Street Address:


Injured Worker's Attorney Contact Information

Street Address: