Arrow Claims Services

Panel of Expert Application Form

Today's Date

Doctor's Name:

Specialty:

Telephone #:

Fax #:

LIC #:

Tax ID#:

SS #:

WCB #:

Fee Schedule

IME Exam:

No Show:

Peer Review

Primary Address

Office Name:

Address:

City/State/Zip:

Please note that the Primary Address will receive all correspondence and medical documents with concern to claimant.

Other Office Location:

Fax These Requirements to (718) 460-6924

Requirements:

Curriculum Vita

Copy of License

Copy of Board Certification

WCB Certification (if applicable)