Rush

*REQUESTOR:


*Phone Number:


Requesting Company:


Date Requested:


Decision Date:


Claim Policy Number:


Return to Work Contact/Supervisor's Contact:


Phone Number:


Claimant's Name:


D.O.B:


Residence Address:


City:


State:
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Zip Code:


Home Number:


Insured Employer:


Business Address:


City:


State:
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Zip Code:


Work Phone Number:


Date of:


Type of (choose one):
Accident
Incident
Injury

Explanation of the part of body injured:


Claimant's Attorney (if applicable):


Special Instructions:


Instructions:
Employment
AOE/COE
Surveillance
Activity Check
Other

Interview:
Claimant
Supervisor
Witness
Third Party
Other

Secure:
Medical Authorization
Police Report
Death Certificate
Personnel File
Other

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