Home/Online client forms/Referral
For adjusters, TPAs, employers and defense counsel
New Client Form
Refer a Nevada workers' compensation file to us. Claimant, injury, employer, physician and the services you need.
New Client Form
Refer a Nevada workers' compensation file to us. Claimant, injury, employer, physician and the services you need.
Step 1 of 8 — Your details
Step 1 — Your details
Just so we know who to reach. Fields marked * are required.
Step 2 — Referring company
Step 3 — The injured worker
Step 4 — The injury and restrictions
Paste the wording from the report rather than summarising it.
Step 5 — Employer at the time of injury
Is modified or alternative duty available?
Step 6 — Treating physician
Step 7 — Attorneys, if any
Step 8 — What you need from us
Services requested
Your signatureSign with a finger on a touchscreen, or draw it with the mouse. This is kept with your form as a record.
Attach any documentsPDF, Word, JPG, PNG or HEIC, up to 12 MB each. They upload when you submit the form.
or drop them here
Other ways to send it
Prefer phone, fax or email?
Fax
855-837-2681
Toll-free.