Request for Service

Short Form


You may attach the “First Report of Injury” at the bottom of this Form; any information already on the “First Report of Injury” may be left blank on this Form.

* Required Field

YOU
* Name:
Company:
Telephone #:
* Email Address:
CLAIMANT
* Name:
Address:
City:
State:
Zip Code:
Telephone #:
SSN:
Date of Birth:
Claim Number:
Date of Injury:
Diagnosis:
Occupation:
AWW:
Benefit:
Employer Name:
Employer Contact Phone Number:
PLAINTIFF ATTORNEY
Firm Name:
Attorney Name:
Telephone #:
DEFENSE ATTORNEY
Firm Name:
Attorney Name:
Telephone #:
PHYSICIAN
Name:
Telephone #:
SECOND PHYSICIAN
Name:
Telephone #:
ADDITIONAL INFORMATION AND INSTRUCTIONS
*Type of Case Management:

Select Jurisdiction:
Additional Instructions:
To attach the First Report of Injury and Medical Records electronically, select “Attaching Medicals” and click “Submit this form to First Rehab.”
An automated message will then be immediately emailed to you, with a link to upload your file(s).
*Forwarding Medicals: