Quick Referral Form

This form will be submitted to a J.D. Wesson & Associates, Inc. Case Manager for processing.  Someone will be in touch with you shortly regarding this referral.

Your Name *
Your E-Mail *
Date
Examiner Name*
Examiner E-Mail *
Examiner Phone Number *
Rush Case?	Yes / No

Claim Number

Case Type	<< Select a Case Type >> Workers' Compensation Subrogation Surveillance Liability Auto SIU Other
Date of Injury/Loss
Insured/Employer
Insured Contact Name
Insured Contact Address
Insured Contact Phone Number
Claimant's Name
Claimant's Address
Claimant's Phone Number
Claimant's Date of Birth
Instructions / Notes / Hours
Suspected Fraud?	Yes / No Undetermined
Workers' Compensation Information
Interview Employee	Yes / No
Interview Employer	Yes / No
Check Subrogation	Yes / No
Obtain Personal File	Yes / No
Conduct DB Background Search	Yes / No
Additional Information
	Reset Submit