Date of Submission:

* Indicates required information.

Name of person sending referral *

Your Email *

Name of Claims Handler *

Insurance Co/Agency *

Insurance Company Address *

Claims Handler's Phone Number *

Claimant's Name *

Claimant's Address *

Claimant's Phone Number

Claimant's Date of Birth *

Insured's Name *

File Number *

Policy Number (if applicable)

Date of Loss

Claimant's Attorney

Claimant's Attorney Address

Attorney's Phone Number

Please select one *

Fit for DutyN/FLiabilityW.C.DisabilityPre-employmentOther

If W.C. - WCB#

If W.C. - SS#

If other:

Claimant's Injuries

Type of Doctor*: (Select at least one)
AcupuncturistAcu/Chiro comboChiropractorDentalENT (otolaryngologist)InternistNeurologistNeurosurgeonOrthopedistPain ManagementPhysiatrist (PM & R)PMR/Acu comboPlastic SurgeonPsychologistPsychiatrist MD

If other type of doctor:

Treating Doctor

Is there a physician you would like us to use?

Comments for the IME Doctor:

Was the Claimant ever examined by NCEI?
YesNo

If Yes, NCEI File Number

When you press send, you will receive a copy via email.

Save Info and submit another IME Request
Yes