Claims Management Referral Form

Name *

First Name

Last Name

Produce Phone *

(###)

###

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Account Contact Phone

(###)

###

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Policy Effective Date

MM

DD

YYYY

Please confirm you have the following documents *

Workers' Compensation Acord Application

Recently valued Loss Runs (preferably the past 4 years)

Current & Prior X-mod Worksheets

Prior Status Reports on Indemnity claims (if available)