AAA Copy
Referral Form
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Date Ordered
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Date Needed
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RUSH SERVICE
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Subpoena (Provide case number below)
Authorization (Upload below or fax to 888-774-2679)
Application for Adjudication (Upload below or fax to 888-774-2679)
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Case #
Requesting Party
Firm/Carrier
*
Representing:
*
Applicant
Defense
Attorney/Adjuster
*
First
Last
Attorney/Adjuster's Phone
*
Attorney/Adjuster's Email
Assistant or Contact Person
First
Last
Assistant's Phone
Assistant's Email
Address
*
Street Address
Address Line 2
City
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Armed Forces Americas
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State
Zip Code
File/Claim #
*
Billing Information
Same as Requesting Party
Company Name
*
Adjuster
*
First
Last
Adjuster's Phone
*
Adjuster's Email
Enter Email
Confirm Email
Assistant or Contact Person
First
Last
Assistant's Phone
Assistant's Email
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Confirm Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
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Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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Nevada
New Hampshire
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New Mexico
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Ohio
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Rhode Island
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
File/Claim #
*
Case Information
Name of Claimant (Records Pertain To:)
*
First
Last
AKAs of Claimant
First
Last
First
Last
First
Last
Claimant's Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Claimant's Date of Birth
Claimant's Social Security #
Employer
*
Case number status:
*
I have a case # (Entered on previous page)
Unassigned
Unfiled
Date of Injury
*
Continuous Trauma
Personal Appearance Required?
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Yes
No
Personal Appearance Date
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Personal Appearance Time
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MM
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PM
Personal Appearance Location (Name of Place)
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Personal Appearance Address
Street Address
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Utah
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Washington
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State
Zip Code
Opposing Counsel
*
Law Firm
Claimant/In Pro Per
Name of Opposing Counsel Law Firm
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Name of Applicant Attorney
*
First
Last
Name of Claimant/In Pro Per
*
First
Last
Address
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Street Address
Address Line 2
City
Alabama
Alaska
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Iowa
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Phone
*
Defense Counsel
*
Law Firm
No Defense Attorney
Name of Defense Firm
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Name of Defense Attorney
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First
Last
Address
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Street Address
Address Line 2
City
Alabama
Alaska
Arizona
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California
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District of Columbia
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Utah
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Washington
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State
Zip Code
Phone
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Photocopying/Service of Process Instructions
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Address of Location 5
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Address of Location 7
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Utah
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City
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California
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Utah
Vermont
Virginia
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West Virginia
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Armed Forces Pacific
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