Transportation | Med Legal Professionals

Name of claimant:

First

Last

Claimant phone number:

Claimant address:

Address Line 1

Address Line 2

City

State

Zip Code

Claimant date of birth:

Injured body part(s)

Claim number:

Adjuster name:

First

Last

Adjuster email:

Adjuster phone number:

Is claimant represented by counsel?

No
Yes

Attorney name:

First

Last

Attorney phone number:

Is pickup address the same as claimant address?

No
Yes

Pickup address:

Address Line 1

Address Line 2

City

State

Zip Code

Transporting to address:

Address Line 1

Address Line 2

City

State

Zip Code

Is claimant ambulatory?

No
Yes

Does claimant require a wheelchair?

No
Yes

Any other transportation needs for this claimant?

Is wait time approved?

No
Yes

Additional comments:

Please upload any supporting documents

Click or drag a file to this area to upload.

Transportation Request

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