No Fault Verification Form Order Number Worker's Compensation Verification Form First Name: * Last Name: * Email Address: * DOB: * Body Parts included in Case: * Date of Injury: * Claim #: * Policy #: * Insurance Carrier Name: * Insurance Carrier Address: * Phone Number: * Fax Number: Adjuster Name: * Adjuster Phone Number: * Variance Fax Number: Which State did the accident occur: * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Have you been scheduled for an Independent Medical Exam? * Yes No
