Professional Administration (MCA)

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Professional Administration (MCA)

Account Representative:

Referral Date:

CLAIMANT INFORMATION

Claimant Name:

Address:

City:

State:

Zip Code:

Phone:

Social Security #:

Gender:

Birth Date:

Jurisdiction State:

Injury Date:

Claim #:

Case Type:

Workers' Compensation

Liability

ADJUSTER INFORMATION

Adjuster's Name:

Carrier/TPA:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Referral Source

DEFENSE ATTORNEY INFORMATION

Attorney's Name:

Firm Name:

Firm Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Referral Source

Send Releases

CC with Allocation

APPLICANT/PLAINTIFF ATTORNEY

Attorney's Name:

Firm Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Referral Source

Send Releases

CC with Allocation

STRUCTURE BROKER INFORMATION

Broker's Name:

Company:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Referral Source

Send Releases

CC with Allocation

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?

Yes

If yes, Initial Funding Amount $

Frequency of payments

Indicate the specific future medical expenses covered under this agreement.

Indicate any restrictions OR exclusions to coverage.

State the duration / term of the agreement.

Upon the death of the Claimant, who will receive any remaining account funds?

If the account is reversionary to Payor, please provide the following information:

% Reversionary to Payor

Tax ID #

Additional Comments

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