Referral Form

First Name

*

Last Name

*

Claim Number

*

Gender

*

Mailing Address

*

Suite/Apt

*

City

*

State

*

Zip Code

*

Physical Address is the same as Mailing Address

Physical Address

*

Suite/Apt

*

City

*

State

*

Zip Code

*

Phone

*

Email Address

**

State/Jurisdiction

Date of Injury

*

Pre-Injury Occupation

*

Description of Injury

*

Current Physical Restrictions provided by a treating physician

*

Average Weekly Wage (AWW)

*

Average Weekly Comp Rate

*

Primary Language

*

Secondary Language

*

Hourly Rate of Pay Employer will Pay while in Transition2Work

*

Is the Injured Worker a Union Member?

Assignments are typically 32-40 hours per week. For alternate hours, check here.

Number of Hours per Week to Schedule while in Transition2Work

*

Assignments are typically between 7A-7P, Mon-Sat. For an alternate schedule, check here.

Work Schedule Preferences

*

Which location would you like the injured worker to work light duty?

Special Accommodations (ie. deaf or hard of hearing, crutches, unrelated injury, etc.)

*

Additional File Information (ie. instructions, PT schedule, appointments, transportation, etc.)

*

Employee ID (Optional)

*

Contact Us: 866-663-9880

To submit a new referral, please complete the form below and click 'Submit'.

Referring Party

Injured Worker and Claim Information

Disability Details

Claims Professional Information

Employer Information

Risk Analyst Information

Litigation Information

Defense Attorney Information

Injured Worker’s Attorney Information

Physician Information

By submitting this referral, you acknowledge and accept our pricing guidelines and service fees. Invoices are submitted to the insurance carrier or TPA unless otherwise indicated.