Step 1

Referral Form

Please select the type of claim from options below. Click Next when done.
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Accident Benefits

Tort Please Specify

Employer

Step 2

2 of 5 completed

Your Information

Fields marked with * are required.

Please provide your Client's Information for reference purposes.

Male Female

Step 3

3 of 5 completed

Please select the type of service you require from options below

Supporting Information:

Step 4

4 of 5 completed

Please select the payment method from options below.

Fundinding Options

Settlement Forecast

Additional Notes

Step 5

5 of 5 completed

Please Select the proposed Report Due Date

DUE DATE

Your report will be submitted to you via Email, SecureDocs or other electronic means.

We will courier a hard copy of the report to you upon completion.

Additional Services