About
Contact
Referral Form
About
Contact
Referral Form
Refer a File to Off2Work:
Off2Work is a nation-wide Return-to-Work (RTW) Program helping employers and employees maintain a healthy, productive and cost-effective relationship. Complete the form below to Refer a File:
Billing Information
*
Indicates required field
Service Requested
*
Workers Comp
NonOccupational
Billing Contact Name
*
First
Last
Bill To
*
Employer
Insurance Carrier
TPA
Billing Email
*
Referring Party
Affiliation
*
Broker
Carrier
Employer
RTW Provider
Self Insured Group
TPA
Other
Referring Company
*
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Referral Contact
*
First
Last
Referral Email
*
Phone Number
*
Fax Number
*
Injured Workers and Claim Information
Name
*
First
Last
Phone Number
*
Email
*
Gender
*
Male
Female
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Claim Number
*
Date of Injury
*
State/Jurisdiction of Injury
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Description of Injury
*
Primary Language
*
Hourly Rate of Pay while in Program
*
Preferred Location of RTW Program
*
At the nonprofit's physical location
Working from home on assigned nonprofit duties
Working from Employer's worksite on assigned nonprofit duties
Pre-Injury Occupation
*
Physician
*
Date of Restriction
*
Current Physical Restrictions
*
Provided by a treating physician or IME
Secondary Language
*
Payroll Period
*
Preferred Schedule
*
Insurance Carrier/Company Name
*
Claim Contact Name
*
First
Last
Claim Contact Email
*
Employer/Company Name
*
Employer Contact Name
*
First
Last
Employer Contact Email
*
Injured Worker's Attorney Firm Name
*
Injured Worker's Attorney Name
*
First
Last
[object Object]
Injured Worker's Attorney Email
*
Additional File Information or Special Instructions
*
Defense Attorney Documents
*
Max file size: 20MB
Submit