EVAN'S Region Customer Service: M-F, 8:30-5
MOTOWN Metro Office: (800) 696-9696
KENOSHA Metro Office: (800) 777-6969

E-Mail: [email protected]
PARAMEDICAL EXAM REQUEST FORM

Use the fields below to enter information. Be sure to select an Insurance Company name.
You can use the Tab key on your keyboard to move through the fields.

INSURANCE COMPANY NAME

POLICY #    
CLIENT
  Last Name   First Name   M.I.
HOME ADDRESS
CITY STATE
ZIP CODE
BUSINESS
ADDRESS
CITY STATE
ZIP CODE

HOME PHONE BUSINESS PHONE
SOCIAL SECURITY # DATE OF BIRTH
AMOUNT OF
COVERAGE		 TYPE OF
INSURANCE
PARAMEDICAL EXAM SHORT FORM URINE
PHYSICIAN EXAM EKG FINGER STICK
FULL BLOOD MINI BLOOD MEASUREMENT ON LAB SLIP
OTHER
SPECIAL REQUIREMENTS 
AGENT'S NAME
AGENT'S PHONE
REQUESTOR NAME
AGENT/AGENCY CODE 
AGENCY NAME
AGENCY PHONE
COMMENTS
YOUR E-MAIL
ADDRESS *
* Be sure to fill in this field if you want status information e-mailed to you.
PAPERWORK TO: Underwriting
COPY TO: Agency Agent
Send form to Motown Send form to Kenosha