Referral Form - Customer Portal

Please specify your relationship to the Injured Party?

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Insurer

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Claimant Solicitor

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Defendant Solicitor

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Third Party Administrator / Adjuster / MGA

Your Details

Your Email address

helpThis address will be used to send you a confirmation of the referral.

Company name

Search Address

Address

Town/City

County

Postcode

Claims Handler

Telephone

Reference

Is this a unilateral or joint instruction?

Unilateral

Joint instruction

Client details

Claimant details

Title

First Name

Last Name

Gender

Male Female Not specified

Address

Search Address

Address

Town/City

County

Postcode

Mobile Number (Recommended)

Landline Number

Work Number

Email Address (if applicable)

Occupation

Date of Birth

Injury Date

Type of Liability/Policy

Please enter liability type

Description of Injury / Illness

Services

Which service is required

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Case Management

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Treatment Only - no case management

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Medico-Legal Report

Case management

Please indicate which Corporè service you require

helpPlease ensure all medical documentation is uploaded.

Please Specify

Other relevant parties

Please select any other relevant parties:-

Insurer

Claimant Solicitor

Defendant Solicitor

Third Party Administrator / Adjuster / MGA

Employer

Policy Holder

Who do we send the invoice to?

Insurer Details

Company name

Search Address

Address

Town/City

County

Postcode

Claims Handler

Telephone

Reference

Claimant Solicitor Details

Company name

Search Address

Address

Town/City

County

Postcode

Solicitor Contact

Telephone

Reference

Has the claimant solicitor agreed to joint party instruction under the Rehab Code 2015?

Yes

We will proceed with this instruction on the basis of Joint Instruction under the Rehabilitation Code 2015. This means we will simultaneously disclose subsequent clinical reports to the claimant’s solicitor. Please confirm you agree to this.

We will contact the claimant’s solicitor to obtain agreement to proceed with this instruction as Joint Instruction under the Rehabilitation Code 2015. This means we will simultaneously disclose subsequent clinical reports to the claimant’s solicitor. Please confirm you agree to this.

Yes

Defendant Solicitor Details

Company name

Search Address

Address

Town/City

County

Postcode

Solicitor Contact

Telephone

Reference

Third Party Administrator / Adjuster / MGA Details

Company name

Search Address

Address

Town/City

County

Postcode

Claims Handler

Telephone

Reference

Employer Details

Company name

Search Address

Address

Town/City

County

Postcode

Contact Name

Telephone

Reference

move_group Copy to Policy Holder

Policy Holder Details

Company name

Search Address

Address

Town/City

County

Postcode

Contact Name

Telephone

Reference

Additional Details

Additional Notes

helpPlease ensure all medical documentation is uploaded.

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Drag & drop your files here or click to browse