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

Insurance Company Order Form

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

Please use the following form for Insurance Company Orders

Insurance Company Information
Adjuster: *
E-mail: * (valid address required)
Company:
Address:
Phone:
Fax:
Client Information
Client Name: *
Address:
Phone:
Buzz No.# (if applicable):
Cell:
Claim #:
Date of Loss:
Appointment Dates/Authorized Destinations:
1.

2.

3.

4.

5.

6.

7.

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.
| | Tel. 1-888-202-3923 © 2008 Rapid City Rehabilitative Transportation Ltd.