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  • About
  • Auto Medical
    • Services
    • NJ Auto Plans
    • 👉 e-Billing Solutions
    • On-line Referrals >
      • Independent Medical Exam (IME)
      • Peer Review
      • Medical Records Review
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      • PRO+
  • Workers’ Compensation
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    • Report a WC Claim
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      • Independent Medical Exam (IME)
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Preparer Information

Preparer's Name
MM slash DD slash YYYY
Is this claim for reporting purposes only?
Did injury occur more than 3 days ago?

Employer Information

Employee Information

MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY
Has it been more 14 days since the accident occured?
Has Employee Returned to Work?
Paid for the day of injury?
Paid While Injured?

Accident Information

MM slash DD slash YYYY
Were Safeguards Provided?
Were Safeguards Used?
Was Accident on Premises?
MM slash DD slash YYYY
Was the accident fatal?
MM slash DD slash YYYY

Medical Provider Information

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