Referral Date:

CLAIMANT INFORMATION

Claimant Name:

Address:

City:

State:

Zip Code:

Phone:

Social Security #:

Gender:

Birth Date:

Jurisdiction State:

Injury Date:

Claim #:

Employer:

Address:

City:

State:

Zip Code:

Phone:

Case Type:

ADJUSTER INFORMATION

Adjuster's Name:

Carrier/TPA:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

DEFENSE ATTORNEY INFORMATION

Attorney's Name:

Firm Name:

Firm Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

APPLICANT/PLAINTIFF ATTORNEY

Attorney's Name:

Firm Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

STRUCTURE BROKER INFORMATION

Broker's Name:

Company:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

CASE QUESTIONS

Has the claimant applied for Social Security benefits?

Is the claimant receiving Social Security benefits?

Is the claimant receiving Medicare benefits?

What diagnosis / body parts are accepted on this claim?

What diagnosis / body parts are denied on this claim?

What is the proposed settlement amount? (if applicable)

Medical Custodial Account Professional Administration for non-Medicare allowable expenses

How is the Medical Custodial Account being funded?

Funded by a single lump sum deposit at time of settlement

Amount $

Funded by a Structured Settlement with periodic payments

Name of Annuity Insurer

Initial Funding Amount $

Annual Annuity Amount $

Will there be periodic distributions?

If yes, Initial Funding Amount $

Frequency of payments

Additional Comments