CLAIMANT INFORMATION First Name: Middle Name: Last Name: Address 1: Address 2: City: State: Zip Code: Date of Birth (mm/dd/yyyy): / / Phone: Email: * Must use a valid email address CLAIM INFORMATION Claim #: Type of Claim: Employer: Occupation: Date of Loss (mm/dd/yy): / / Last Day Worked (mm/dd/yy): / / Treating Physician / Therapist(s): Diagnosis: Comments: IME APPOINTMENT INFORMATION Specialty Requested: Verbal Report? Yes No Sending Medical Records to US Evaluation Services? Yes No *Please send all correspondence to U.S. Evaluation Services. A cover letter is required from the requesting party to ensure we have all instructions for the IME requested. CLAIMANT NOTIFICATION Claimant to be Notified by U.S. Evaluation Services? Yes No If Yes, List Method: REQUESTING PARTY INFORMATION Requested By: Company Name: Address: City: State: Zip Code: Phone: Fax: Email: * Must use a valid email address