*Denotes required information.

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Service Being Requested

• Medicare Lien Verification
• MSA
• Medical Cost Projection
• Social Security Verification

Case Classification

• WC
• Liability
• No-Fault
• Longshore
• Jones Act

Adjuster Information

• Referring Party Name *
• Referring Party Address *
• Referring Party Address Line 2
• City

  State / Province / Region Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico United States Minor Outlying Islands Virgin Islands
• Postal / Zip Code

  Country AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
• Referring Party Phone *
• Excess Carrier Name *
• Referring Party Email *
• Preferred Structure Settlement Broker
• Excess Carrier

Referring Party Information

• Claimant Name *
• Date of Injury *

  Claim Number
• Claimant Address
• Claimant Address Line 2
• City

  State/Providence/Region Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico United States Minor Outlying Islands Virgin Islands
• Jurisdiction

  Postal / Zip Code
• Claimant Social Security Number *

  Claimant Date of Birth *
• Claimant Employer
• Claimant Employer Address
• Claimant Employer Phone Number
• Defense Counsel's Contact Information
• Claimant's Counsel's Contact Information

Claimant Case Information

• How did injury occur?
• Are there any denied conditions?
  • Yes
  • No
  List of denied conditions
• What was the specific nature of the accepted injury?
• Please give title and brief description of the Claimants job at the time of injury.
• Is Claimant currently receiving Social Security Disability benefits?
  • Yes
  • No
• Is Claimant currently eligible to receive Medicare benefits?
  • Yes
  • No
• What is the total amount of indemnity benefits paid to date?
• Has a settlement been reached?
  • Yes
  • No
  Please provide the estimated medical settlement amount.
• Tentative Settlement Range
• How is set aside to be paid?
  • Out of settlement proceeds
  • Above and beyond settlement proceeds

Please remember to upload copies of your supporting documentation. A list of the documentation required and a link to our secure file service will be provided on the next page as well as via an email to the address you’ve provided above.