Claim Number
*
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
The following section pertains to the activity regarding your claim that you are participating in.
Check the appropriate activity
*
Made phone call
Received phone call
Sent an email
Received an email
Sent letter
Received letter
Sent a fax
Received a Fax
Setup a Meeting
Had a Meeting
Who was the activity with?
Case Manager
Eligibility Adjudicator
Case Manager
Nurse Consultant
Return-to-Work Specialist
Appeals Resolution Officer
My Family Doctor
Other Health Care Professional
My Employer
My Union Rep
My retraining facility (College, University, ESL)
Name of individual who the activity was with.
*
First Name
Last Name
Additional names and Title
Describe what took place during the activity
*
Expected outcome from that activity?
Document Upload
Browse Files
Upload any documents specifically pertaining to this activity
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of
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