Legal 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 - Legal

Referral Source 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:

Legal Firm:

Referral Date (YYYY / MM / DD):

Referral Contact:

Telephone No.:

Fax No.:

Location (Office):

Address:

Email:

Legal Assistant / Law Clerk:

Telephone No.:

Fax No.:

Email:

Principal Insurer Information

Insurer:

Claim No.:

Insurer Location (Branch):

Telephone No.:

Fax No.:

Email:

Adjuster Name:

Client Information

File 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:

Plaintiff Attorney (If Applicable):

Name:

Address:

City:

Province:

Postal Code:

Email:

Telephone No.:

Fax No.:

Defence Attorney (If Applicable):

Name:

Address:

City:

Province:

Postal Code:

Email:

Telephone No.:

Fax No.:

Injuries:

Injuries Other Please State:

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Special Services

Transportation

Interpreter

Interpreter Language:

Telemedicine

Questions / Comments