Rapid City Transportation: Contact Us/Order

	Order Form for Insurance Adjusters
	Order Form for Case Managers/OT's
	Order Form for Law Firms

Order Form for Case Managers/OT's

Please allow 24 business hours for processing. Same day orders must be faxed to us at 905-831-1115. Thank you.

Medical Clinic or Assessment Centre

Name: *

E-mail: * (valid address required)

Title:

Company:

Address:

Phone:

Fax:

Billing Information if Different from Above

Billing Contact/Adjuster:

Company:

Address:

Phone:

Fax:

E-mail:

Client Information

Client Name: *

Address:

Phone:

Cell:

Claim #:

Date of Loss:

Appointment Dates/Authorized Destinations:

1.
2.
3.
4.
5.
6.
Special Instructions/Additional Information

If you require same-day service please call 416-266-1500 immediately after submitting your order on this form. Please quote the reference numbers that will be e-mailed to you after submitting this form.