Please enable JavaScript in your browser to complete this form. - Step 1 of 2Select Referral Type *Case ReferralLitigation ReferralReasonable & Necessary Declaration ReferralCase ReferralLitigation ReferralReasonable & Necessary Declaration ReferralRequest Type *Independent Medical ExamRecord ReviewIs this a Worker's Compensation case? *YesNoRequest Type *Trial TestimonyArbitration TestimonyPerpetuation DepositionDeclaration in Lieu of Live TestimonyRequest Type *Reasonable & Necessary DeclarationYour InformationName *Email *Company Name *Attorney NamePlease complete if you are not the Attorney.Phone NumberAddressCase InformationIs this a rush request?YesNoSpecialty or Expert(s) Needed *Records VolumeCase VenueClaim NumberReport Due DateTeam Connect NumberExplanation of DeclarationClaimant InformationClaimant Name *FirstLastDate of Birth *Claimant LocationTrial/Testimony InformationDuration of Time Needed1 Hour2 Hours3 Hours1/2 DayFull DayPreference of Date and Time to TestifyDateTimeLocation of TestimonyNextAdditional Helpful InformationThis information is not required to get started, but may help to expedite the process. You may be asked for this information later if you choose not to provide it now.Case Information ContinuedDate of LossCause NumberDiscovery Cut Off DateTrial DateCase CaptionArbitration DateClaimant Information ContinuedClaimant's AttorneyClaimant's Attorney EmailClaimant's Attorney AddressClaimant's Attorney Phone NumberInjuries ClaimedMechanism of InjuryTreating ProvidersUpload Your RecordsThese can always be uploaded later by using the link under "Customers". Submit