Juvo Referral Form

1

What is your name?* This field is required.If referring on behalf of another person please put your name here.

First Name

Last Name

2

What is your email address?* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

Are you the handling claims adjuster?* This field is required.

YESNO

5

Tell us about the handling adjuster* This field is required.

First Name

Last Name

Please enter adjuster's email

Phone Number

6

What is the claim number?* This field is required.If there is more than one, please separate each by using a comma.

7

Injured Worker's Name* This field is required.

First Name

Last Name

8

ADJ number(s)Please separate multiple ADJ numbers with a comma

9

What service(s) would you like us to perform?* This field is required.You may select multiple options

Contact or Meet Injured worker.

Walk Through Settlement

Document Drafting

EDD Check/Resolution

Hearing Rep Services (filings, dismissals, etc)

Other Request

10

Injured Worker Phone Number

Area Code

Phone Number

11

Is the injured worker still employed with the employer?

YESNO

12

Is the injured worker represented?

YESNO

13

Has the injured worker already agreed to the settlement?We like to know where the injured worker is in the process.

YESNO

14

Upcoming hearing dateIf there is a hearing date please provide it here.

Date

15

Any special instructions or additional information?

16

Upload your document(s)(If we have system access you can skip this)

Drag and drop files here

Select files to upload

17

Account NameWhich account does this referral pertain to?

Example: Lowes, Disney, Zurich, etc

18