Record Express, LLC :: Order :: Record Retrieval

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Record Request Order Form

SECTION A

* Required Field
* Customer / Firm Name:	Date:

Address1:

* Phone:

Address2:

Fax:

Contact Person:	Direct Dial:	Email:
Paralegal/Secretary:	Direct Dial:	Email:

Billing Address (if different):
Policy Number:

Order a Summary of Significant Medical Conditions report

Customer Represents:

Plaintiff

Defendant

Claimant / Insured Other

SECTION B

* Record Pertains To:

* SSN#

AKA:

* DOB:

DOD:

Address1:

Address2:

Court or Administrative Body Name:

Case#:

Case Group Name:

Case Caption:

Opposing Counsel:

Phone:

Expert Report Deadline:

Trial Date:

Check if Military Records Section is Applicable

SECTION C

MILITARY RECORDS(Check all that apply):

Veteran Admin

Military Service

Branch of Armed Service:

Years Served:

Officer or Enlisted? :

Service No. :

Place of Birth:

Check if Internal Revenue Section is Applicable

SECTION D

INTERNAL REVENUE SERVICE

Tax Returns for Years:

If Taxpayer filed Joint Return, list all names, social security numbers and addresses as they appeared on returns:

Check if Social Security/ Disability Claims Section is Applicable

SECTION E

SOCIAL SECURITY ADMINISTRATION EARNING STATEMENT AND/OR DISABILITY ClAIM RECORDS :

Certified Earnings Statement for years:

from

If Disability was filed, list City and State where filed:

Disability Claim No.:

Date Claim was filed:

Check if Workers Compensation Section is Applicable

SECTION F

WORKERS COMPENSATION

Date of Injury:

City and State Where Claim was Filed:

Claim No.

Employer when Injured:

Check if Employment Records Section is Applicable

SECTION G

EMPLOYMENT RECORDS

Name of Employer :

Years Employed:

Address of Employer :

Phone of Employer :

Check if Union Records Section is Applicable

SECTION H

UNION RECORDS

Name and Local No. of Union:

Trade of Union:

Address of Union Hall:

Phone Number : Years of Membership:

Check if Medical Records Section is Applicable

Special Instructions

* Please Fax Authorizations to: (513) 685-7330 or Email to: info@recordexpressllc.com

Select the method you will use to send authorizations:

Fax