External Review Forms
External Review Referral Form
Insurers should use this form, which is available in three formats, to request assignment of an independent review organization.
Interactive version: Fill in the fields and submit the form to the Insurance Division.
Word version: Download the form, enter the information, and e-mail the form to us as an attachment, or fax or mail it to us.
PDF version: Download the form, fill it out, and fax or mail it to us.