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: