Cancellation Request 

Today’s Date: 

Claimant: 

Social Security #: 

Date of Birth: 

Date of Exam/Deposition: 

Insurance Co.: 

Address:  

City:

State:      Zip/Postal code: 

Contact Person: 

Phone: 

Fax:

Email: 

Canceling: IME Deposition

Attorney:   

Firm:   

Address:  

City:

State:  Zip/Postal code: 

Contact: 

Phone: 

Fax:

Email:

Please direct questions to Stacey Gump,

Medicolegal Administrative Coordinator