We are aligned with Health Insurance Portability and Accountability Act of 1996

Submitted Information

The Case
Case Type
WCB Number
WCB Address
Claim Number
Date of Accident
Name of Insured
Name of Adjuster
Insurance Company
Phone of Adjuster
Fax of Adjuster
Attorneys & Doctors
Name of Attorney
Attorney's Phone
Attorney's Fax
Attorney's Address
Attorney's Address Line 2
Attorney's City
Attorney's State
Attorney's Zip Code
Name of Doctor
Doctor's Phone
Doctor's Fax
Doctor's Address
Doctor's Address Line 2
Doctor's City
Doctor's State
Doctor's Zip Code
The Claimant
Claimant's Name
Job Title
Date of Birth
Phone Number
Phone Number 2
Home Address
Home Address Line 2
City
State
Zip Code
The IME
Reason for IME
Specialty Required
Injuries
Instructions
Get Video Recording
Files Uploaded
Don't have an account? Takes only 1 min.
Recover your password
Type your account email and an email will be sent with instructions to recover your password.
Popover_checkmark Created with Sketch. Email with instructions was successfully sent to your address!

Create an account to submit and save forms.
It’s 100% free and safe.
  • This field is hidden when viewing the form
  • (Required)
  • (Required)
  • (Required)
Already have an account?