Online Referral | IW Care Connection, Inc.

Online Referral

IW Care Connection Online Referral Form

Adjuster Name *

First Name

Insurance Company

Last Name

Is this claim litigated?

Adjuster Address

Insurance State

Adjuster's Phone Number *

Adjuster's Email *

Insurance Company City

Referral Type

Insurance Company Fax

Insurance Company Zip

Preferred Method of Communication

Claim Number

Other Claim Identifiers

Injured Worker

Phone with Ext

Alternate Contact

Primary Language

Employee Address

Employee City

Employee State

Employee Zip

Employee Gender

Date of Injury

Date of Birth

SSN

Treating Physician

Specialty

Treating Physician Phone w/ext

Treating Physician Fax

Treating Physician Address

Treating Physician City

Treating Physician State

Treating Physician Zip

Reason for Referral / Other Special Instructions

If you are human, leave this field blank.

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