This is a sample of our IME request form for a Workers' Compensation case. Forms for liability and no-fault cases will differ in detail, but are pre-filled with your information as in this example. Scroll down to see the file attachment feature. Use your browser's "back" button to return to the page you linked from.

Please note:
The text fields for notes and special instructions allow you to enter all the information that is pertinent to your request; you do not have to edit for brevity. Thorough and complete instructions and comments will help speed processing.
Files and other information to be submitted with the form can be in any format that is suitable for attachment to an e-mail (Microsoft Word or Excel files, RTF text files, Adobe Acrobat .pdf files, or others). Before submitting the form, click the "Attach" button and send your attachments with the pop-up e-mail form.
After submitting the form you will receive an automated e-mail response confirming our receipt of your request.
Other responses, such as courier or appointment schedules or requests for more information, will follow shortly.

Part 1: Claim Information
Date:
Requested by:
Company:
Address:
City:
State: ZIP:
Phone: FAX:
e-mail:

Part 2: Examinee Information
Claimant Name: SSN:
Claimant Address:
City:
State: ZIP:
Phone:
Claimant Attorney:
Attorney Address:
City:
State: ZIP:  
Attorney Phone:  
Claim Number:  
WCB Number:  
Date of accident:  
Employer:  

Part 3: Examination Requirements
If Re-examination, Prior Exam Date:
Specialties Required:
Ortho Neuro Neuro Surgical Surgeon
PMR Psychiatric ENT Chiro
Internal Medical Dental Oral Surgery Cardiology
Other:
Render Specific Opinion For:
Diagnosis Causal Relationship
Prognosis Need for Surgery
Further Treatment and Frequency Permanency Rating
Degree of Current Disability Apportionment of Disability
Has an end result / MMI been reached? M & S Statement (2nd Injury Law)
Can claimant return to work? Can claimant perform light / modified duty?
Scheduled Loss of Use Only  
Specific Job Capabilities (attach job description or include in materials for pickup)
Medical Necessity of Testing Performed (Specify test type and date below)
Discussion of Findings File Review
Film Review (List films to be reviewed below)

Special Instructions / Comments
Attachments:
Bill of Particulars Medicals Other (specify below)
Please schedule pickup of record materials