Tangiers International | Case Referral Form

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Client Information

Client Company*

Client Representative*

Client Phone Number

Client Email Address*

Assignment Type

Claim Number*

Claimant Information

Name

Address

Assignment Country

Phone Number

Email Address

Date of Birth

Passport/ID Number

Current Location

Date of Loss

Facts of Loss

Injury

Occupation

Employer Information

Company

Point of Contact

Email Address

Phone Number

Mailing Address

Beneficiary Information

Principal Beneficiary

Relationship

Phone Number

Email Address

Mailing Address

If The Claimant is incapacitated, please provide a family POC

Point of Contact

Phone Number

Email Address

Mailing Address

Objectives

Objectives*

**Please provide all supporting documents for this claim: LS202, Incident Report, etc.**

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Case Referral Form

Client Information

Claimant Information

Employer Information

Beneficiary Information

If The Claimant is incapacitated, please provide a family POC

Objectives

Testimonials

Awards

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Case Referral Form

Client Information

Claimant Information

Employer Information

Beneficiary Information

If The Claimant is incapacitated, please provide a family POC

Objectives

Testimonials

Awards

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