FIELD CASE MANAGEMENTService InformationService RequestNew FileReopen FileInitial EvaluationField Case ManagementTelephonic Case ManagementOne Task ManagementInitial/One-Shot AssignemntCost ProjectionLifetime Cost ProjectionType of CoverageAuto Liability B.I.Auto - No-FaultDisabilityGeneral LiabilityHealthHome OwnersOtherWorkers' CompnsationClaimant InformationName(Required)AddressCityStateZipPhone(Required)Cell PhoneSocial SecurityDate of Birth(Required) MM slash DD slash YYYY Contact PersonAddressCityStateZipPhoneCell PhoneEmployer InformationEmployer Name(Required)Address(Required)City(Required)State(Required)Zip(Required)Phone(Required)FaxNature of BusinessContact Person(Required)Contact Phone(Required)Contact EmailCarrier InformationCarrier Information(Required)Carrier(Required)AddressCityStateZipAdjusterPhone(Required)FaxInsured AmountPolicy LimitDeductible AmountAccident InformationAccident Date and Time(Required)Claim Number(Required)DiagnosisPhysician(s)Hospital(s)Contact Phone or Beeper NumberPatient Attorney InformationIs the patient represented? Yes NoAttorney NameFirm NameAddressCityStateZipPhoneFaxCommentsComments, Instructions, and Other Pertinent Data