This online encrypted form will send your case assignment directly to our home office. We will send you an email confirming the assignment has been received and reviewed by our office before the end of the business day. If you do not receive a confirmation email, please contact us by phone at 954-788-1190, or email us at firstname.lastname@example.org.
A PDF download form is also available. Download the form to use as a template. Email or fax the completed form to our office.
To move forward and back within the form progress, use the Previous and Next buttons within the form. Using your browser’s back button will bring you to your previous webpage.
Clicking the “Assign Case” link at the top of the page will reset the form and clear all entries. If you accidentally navigate away, using your browser’s forward and back buttons should keep all of your data saved in the form. Forms can not be saved between browser sessions for privacy and security.