MSA Allocation

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MSA Allocation

Account Representative:

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:

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

CASE QUESTIONS

Has the claimant applied for Social Security benefits?

Yes

Unknown

Is the claimant receiving Social Security benefits?

Yes

Unknown

Is the claimant receiving Medicare benefits?

Yes

Unknown

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)

Medicare Set-Aside Professional Administration

How is the Medicare Set-Aside 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 $

Additional Comments

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