Insurance Referral Form Please use this form if you are a doctor, healthcare professional, case-manager, or lawyer referring a person that has an active Accident Benefit Claim due to a motor vehicle accident. Referral Source: Name of person completing this form*: Relationship to Client*: Self Family Physician Specialist Physician Case Manager Occupational Therapist Lawyer / Paralegal Other Healthcare Professional Name of Clinic/Company/Firm*: Address*: Phone*: Fax: Email*: Client Information: Client Last Name*: Client First Name*: Date of Birth*: Calendar Gender*: MaleFemaleOther Client Address*: City*: Postal Code*: Client Phone*: Client Alternative Phone: Client Email: Booking arrangements (Check all that apply): To book appointment please contact*: Contact client directly Contact family member/friend to book Preferred Assessment Location*: HamiltonMississaugaMarkhamWhitbyBellevilleKingstonClient's homeUnsure, please contact client Physician Information: Does the client have a physician?*: YesNo Insurance Company Name*: City or Town or Branch (if applicable): Adjuster Last Name*: Adjuster First Name*: Adjuster Telephone*: Adjuster Fax: Name of Policy Holder*: Applicant Other Is there other insurance coverage that may cover our services?*: YesNoUnsure Lawyer Information: Is the client being represented by a legal firm?*: YesNo Please let us know if you have any questions or comments related to this referral: How did you hear about us?*: I have referred before Saint Elizabeth Website Other Internet / web-search Presentation Conference Other Prefer not to say