Please answer the questions below so that we will have information to create your quote.

1. Do you have multiple locations that need to be served?
   Yes   No If so, how many?
   
   
2. Please provide the number of medical only claims,
   
   and lost time claims you had in the last year.
   If you wish, you may provide a printout of your claims by email or fax.


3. We use qualified licensed attorneys who specialize in workers' compensation. Please state the number of hearings you had last year,
   
   
   and indicate whether or not you will want legal representation at your hearings?
   Yes   No
   
   
4. We recommend a comprehensive file review/strategy meeting should take place at least once a year. Would you prefer this type of meeting more frequently?
   Yes   No
   
   If so, how many?


5. Are you seeking the establishment of a return-to-work, transitional work or drug-free workplace program?
   Yes   No
   
   If so, please specify.
   
   
6. We can identify and pursue negligent third parties. Would you like us to pursue subrogation recovery?
   Yes   No
   
   
7. We can audit medical bills for accuracy, relationship to claim and medical necessity. How many medical bills are processed yearly?
   
   
8. Case management contains costs by eliminating or reducing utilization of resources. Would you prefer to use case management on your claims?
   Yes   No
   
   If so, approximately how many claims yearly would qualify for case management?
   
9. A managed care review ensures that only appropriate and necessary care is delivered in the most appropriate setting by qualified professionals. Would you prefer to use managed care reviews?
   Yes   No
   
   If so, approximately how many reviews would be needed a year?
   
   
10. If you are seeking any of our other services, please list those here:
    
    

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