BI-RIME 01/06 Request for Independent Medical Examination Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 1. Claimant’s Name 2. Claim Number 3. Social Security Number 4. Date of Injury 5. Body Part(s) to be examined I, (write your name) _____________________________________________________ request to be sent out for an independent medical examination for an evaluation and determination regarding permanent partial impairment. 6. Mailing Address 7. Phone Number (include area code) Claimant’s Signature Date BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332-3151 American LegalNet, Inc. www.USCourtForms.com