Casualty Online Referral Form

Corporate Head Office
7050 Weston Road, Suite 240
Woodbridge, Ontario, L4L 8G7
Tel: 905-851-8039
Toll Free: 1-877-563-2437

Online Referral Form - Casualty

Insurer Information

If you have submitted an online referral in the past, enter your email address here and click "Load Profile".
(Note: Any changes you make to your profile will be saved automatically.)

Returning Customer Email:

Insurer:

Referral Date (YYYY / MM / DD):

Adjuster:

Telephone No.:

Fax No.:

Location (Branch):

Address:

Adjuster Email:

AB Assistant

Telephone No.:

Fax No.:

Email:

Principal Insurer Information

Insurer Name:

Location (Branch):

Email:

Telephone No.:

Fax No.:

Claimant Information

Claim No.:

Date of Loss (YYYY / MM / DD):

Last Name:

First Name

Middle Initial:

Date Of Birth (YYYY / MM / DD):

Age:

Gender: Male Female

Telephone No.:

Address:

City:

Province:

Postal Code:

Representative (if applicable):

Telephone No.:

Fax No.:

Email:

Address:

City:

Province:

Postal Code:

Injuries:

Injuries Other Please State:

Benefit Categories (mark if applicable)

Attendant Care	House Keeping And Home Maintenance Benefit	Income Replacement Benefit - Post-104 Week
Non-Earner Benefit	Medical / Rehabilitation	Caregiver Benefit
Catastrophic Impairment	Income Replacement Benefit	Caregiver - Post-104 Week
MIG Determination

Casualty Assessments Required

Paper Review	In Person	Paper Review	In Person	Paper Review	In Person
	Cardiology		MIG - Physiatrist		Physiatry
	Chiropractic		MIG - Physiotherapy		Physician(GP)
	Dental		Neurology		Physiotherapy
	FAE		Neuropsychology		Plastic Surgery
	Gerentology		Neurosurgery		Psychiatry
	IE - Neurocognitive Ax		OT-In Home		Psychology
	Internal Medicine		OT-In Home with Form 1		Psychovocational
	Job Site Analysis		Ophthalmology		Rheumatology
	Massage Therapy		Oral Surgery		Speech-Language Pathology
	MIG - Chiropractic		Orthopaedic		TSA / Vocational
	MIG - General Practitioner		Otolaryngology		Other
	MIG - Orthopaedic Surgeon		Paediatric Specialty	Other Please State:

Type Of Assessment:

Special Services

Transportation

Interpreter

Interpreter Language:

Telemedicine

Questions / Comments