Toll-Free: 866-663-9880
Phone: 813-663-9880
Fax: 813-663-9886

workers compensation return to work program

Start Cutting Workers' Compensation Costs Now

For custom service, we'd be happy to stop by your office, pick up your claim file and answer any questions that you may have. Click the document below to fill out one of our forms online, or click the PDF icon to download a PDF version of the form to fill out offline. You can fax the completed form to us, as well as any documentation relating to the case, at 813-663-9886 or we'll even stop by and pick it up for you.We can even take your information over the phone. Call us toll-free at 866-663-9880.

Every day that you wait is costing you money. Let us help you today!

Referral Forms

Form	Download
Re-Employment Services	43kb
Transition2Work	281kb

Insurance Company Name:	Date of Referral
Address:	City:	State:	Zip:
Phone:		Fax:	Adjuster Email:
Adjuster Name:		Adjuster Title:

Injured Worker Name: Male Female		Claim Number:	Date of Loss:
Address:		Last 4 digits of SSN:	DOB:	Occupation:
City:	State:	Zip:	Injured worker Phone:	Jurisdiction:
Language: English Spanish Bilingual:English/Spanish Other(specify)		AWW:	Comp Rate:
Employer:		Employer Contact:
Employer Email:		Employer Phone:	Employer Fax:

Litigation Issues:	Mediation Date:	Hearing Date:
Claimant Attorney:	Phone:
Defence Attorney:	Phone:

File Referrals > Click Here

Start Cutting Workers' Compensation Costs Now

Referral Forms

Online Referral Form

Injured Worker & Employer Information:

Return to Work

Litigation Status

Physician Information

For Transition2Work Referrals Only

Physical Restrictions and Special Instructions

Physician:	Phone:
Physician:	Phone: