CASE MANAGEMENT REFERRAL

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    Preparer's Information

    Type of Claim:

    <Report OnlyTelephonic Case MgmtField Case Mgmt

    General Information

    Employer Information

    Are your Workers Compensation panels posted?

    YesNo

    Are your Notification Forms signed? (For PA)

    YesNo

    Employee Information

    MaleFemale

    SingleMarriedDivorcedWidowed

    Full TimePart TimeVolunteerSeasonalOther

    YesNo

    YesNo

    YesNo

    YesNo

    Accident Information

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Witness Information

    Medical Provider Information

    YesNo

    Zip Code

    YesNo

    YesNo

    Agent Information

    Comments