Recent Posts COVID-19 (Coronavirus) Related Resources Strategies to Support Employees’ Ongoing Employment Training is the key to compliance Keep Calm and Remember the “Interactive Process” Building a Better Return-to-Work Program Contact Us Name * RequiredEmail Address * Required Message * RequiredOpt-in checkboxPlease note we will never sell nor will we ever use your information inappropriately. Sign up for our distribution list Featured Downloads Marijuana Use in California - An Employer's Guide to Rights and Obligations DFEH Reasonable Accommodations Packet DFEH Sexual Harassment Poster Download Roberta's Resume Download Roberta's Bio DFEH Workplace Harassment Guide DFEH Sexual Harassment Brochure DMG Referral Form The Interactive Process - JAN Network Standing For Health - @Work Magazine Referral Submission New This referral is used by DMG customers to submit injured worker's information in order to star the process. 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Employee InformationName First Last Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone * RequiredOccupation / TitleDate of Birth - must be mm/dd/yyyy format Date of Injury - must be mm/dd/yyyy format If applicable, please enter a date of injury.Claim NumberIf applicable, please enter a claim number.Disability / Injury isOccupational / On the JobNon-Occupational Employer InformationCompany Name * RequiredAddress * Required Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Name * RequiredContact Email * Required Contact Telephone * RequiredContact Fax Treating Physician InformationHas a Treating Physician been selected? * RequiredYes. There is a Treating PhysicianNo. There is no Treating Physician at this timeDoctor NameAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Doctor Email Doctor TelephoneDoctor Fax Insurance Company InformationHas an Insurance Carrier been select? * RequiredYes. An Insurance Carrier has been selectedNo. An Insurance Carrier has not been selectedInsurance Company Name * RequiredContact Name * RequiredAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Email Contact Telephone * RequiredContact Fax Applicant Attorney InformationIs Employee Represented? * RequiredYes. Employee is representedNo. Employee is NOT representedFirm NameAttorney NameAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email TelephoneFax Defense Attorney InformationIs Employer Represented? * RequiredYes. The employer is representedNo. The employer is NOT representedFirm NameAttorney NameAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email TelephoneFax CommentsUpload File(s) Drop files here or Accepted file types: pdf, jpg, gif, png. Please upload any documents that may be useful for this referralMaximum file size - 64 mega bytes. This iframe contains the logic required to handle Ajax powered Gravity Forms.
