Client Assignment Form: Printable Version (Insurance Related Cases Only)
Date Assigned: ____________________ Claim / File #: ___________________________________
Loss Date: _____________ Insured: ______________________________ Budget: ____________
SUBJECT / CLAIMANT INFORMATION
Subject Name: __________________________________________ Date of Birth: _______________
Address: ________________________________________________________________________
City / State / Zip:___________________________________________________________________
Telephone: (____) _________________ S.S. #: __________________ Race__________ Sex______
Physical Description: Height: ______ Weight: ___________ Build: ___________ Hair: _________
Distinguishing Features: _____________________________________________________________
Marital Status: _________________ Spouse: _________________ Children: __________________
Injury Type: ____________________________ Restrictions: _______________________________
Is Claimant Represented? __Y __N Attorney: __________________________________________
Employer (If currently employed): _____________________________________________________
Employment Schedule: _______________________ Therapy Schedule: _______________________
Therapy / Medical Information: _______________________________________________________
Other Helpful Information: ___________________________________________________________
Special handling Instructions: _________________________________________________________
CLIENT / REQUESTER INFORMATION
Requester: _____________________________ Phone: ______________________ Ext: __________
Company: ____________________________________________ Fax: ________________________
Address: _________________________________________________________________________
Submit by Facsimile to: (814) 836-0812