(909) 581-9874 Referrals@AAACopy.net

Congratulations and thank you for taking advantage of our promotional offer! If this is your first order with us, we’ll bill you at 20% off the fee schedule rate. Thanks for giving us a try!

ORDER BASICS
Job Type:
Request Date: (MM/DD/YYYY)
Due Date: (MM/DD/YYYY)
We treat all orders as RUSH requests, but please check this box if your order is extra time-sensitive.
Records Delivery Options:
CASE INFO
Case Caption:
Case Number:
(Check below if no case #)
Court (optional):
Do you have a signed Authorization?
Click button to upload Authorization form or other documents:
APPLICANT/CLAIMANT/PLAINTIFF
Applicant's Name:
Applicant's Address:
Applicant's Phone:
-
Date(s) of Injury (MM/DD/YYYY):
-
Applicant's SSN:
Applicant's DOB: (MM/DD/YYYY)
AKA info - Very important! Please list any and all alternate names, DOBs, and SSNs for claimant.
REQUESTING PARTY
Representing:
Requesting Firm/Company:
File Number:
Address:
Handling Attorney or Adjuster:
Email:
Phone:
-
Fax:
-
Name of Assistant:
Assistant's Email:
Assistant's Phone:
-
EMPLOYER/INSURED
Employer/Insured:
Employer's Address: (Optional)
INSURANCE/BILLING INFO
Billing party same as requesting party?
Claim Number:*Required
Adjuster:
Adjuster's Phone:
-
Adjuster's Fax:
-
Carrier/Claims Administrator:
Billing Address:
OPPOSING COUNSEL
Opposing Counsel Firm:
Opposing Attorney's Name:
Opposing Counsel's Phone:
-
Opposing Counsel's Fax:
-
Opposing Counsel's Address:
DELIVERY INSTRUCTIONS
Send Records To: (Check all that apply)
Additional Party:
ATTN:
Additional Party's Address:
ADDITIONAL OR SPECIAL INSTRUCTIONS
PROCEED TO NEXT PAGE TO ENTER RECORDS LOCATIONS
COPYING INSTRUCTIONS
(1) Location:
(1) Location Phone:
-
(1) Location Fax:
-
(1) Location Address:
(1) Location Record Type:
(1) Location Special Instructions:
(2) Location:
(2) Location Phone:
-
(2) Location Fax:
-
(2) Location Address:
(2) Location Record Type:
(2) Location Special Instructions:
(3) Location:
(3) Location Phone:
-
(3) Location Fax:
-
(3) Location Address:
(3) Location Record Type:
(3) Location Special Instructions:
(4) Location:
(4) Location Phone:
-
(4) Location Fax:
-
(4) Location Address:
(4) Location Record Type:
(4) Location Special Instructions:
(5) Location:
(5) Location Phone:
-
(5) Location Fax:
-
(5) Location Address:
(5) Location Record Type:
(5) Location Special Instructions:
(6) Location:
(6) Location Phone:
-
(6) Location Fax:
-
(6) Location Address:
(6) Location Record Type:
(6) Location Special Instructions:
(7) Location:
(7) Location Phone:
-
(7) Location Fax:
-
(7) Location Address:
(7) Location Record Type:
(7) Location Special Instructions:
(8) Location:
(8) Location Phone:
-
(8) Location Fax:
-
(8) Location Address:
(8) Location Record Type:
(8) Location Special Instructions:
(9) Location:
(9) Location Phone:
-
(9) Location Fax:
-
(9) Location Address:
(9) Location Record Type:
(9) Location Special Instructions:
(10) Location:
(10) Location Phone:
-
(10) Location Fax:
-
(10) Location Address:
(10) Location Record Type:
(10) Location Special Instructions:
(11) Location:
(11) Location Phone:
-
(11) Location Fax:
-
(11) Location Address:
(11) Location Record Type:
(11) Location Special Instructions:
(12) Location:
(12) Location Phone:
-
(12) Location Fax:
-
(12) Location Address:

If you need to request additional locations,
reply to your confirmation email after
submitting the formĀ or use our
add-on order form.

(12) Location Record Type:
(12) Location Special Instructions:
Your Name:*Required
Your Email: (For Order Confirmation)*Required
Verify that you're a real person:
(Optional) How were you referred to us?

Congratulations and thank you for taking advantage of our promotional offer! If this is your first order with us, we’ll bill you at 20% off the fee schedule rate. Thanks for giving us a try!

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