Name:
Date of Birth:
Claim #:
Date of Loss:
Policy #:
Policy Holder:
Street Address:
City:
Postal Code:
Home Telephone Number:
Cellphone Number
Work Number
Diagnosis:
Other Health Issues:
Is this an Insurer's Examination:	yes no
Is this a reassessment?	yes no
Other Contact Person:
Telephone #:
Check which one applies:	IRB Caregiver Attendant Care Home Maintenance Non Earner
English Speaking? (Note: If not English speaking KRA will arrange an interpreter)	yes other
If not English Speaking, which language?
Special Instructions:
Referral Date:
Claims Adjuster:
Insurance Company:
Address:
Phone Number:
Fax Number:
Legal Firm?
Legal Contact Person:
Telephone Number:
Fax:
Do you have any documentation on file, e.g., Disability Certificate?	Yes No
Please send client documentation to KRA, 16 Sims Crescent, Unit 3, Richmond Hill, Ontario, L4B 2P1. Tel: 905-771-9153 fax: 905-771-1177