To start a MSA Referral, click the YES box below
YES, I'd like to begin the referral process
Referring Party
What is your relationship to the claim/settlement? (required)
*
Plaintiff Attorney
Settlement Consultant
Trustee
Other
Name
First Name
Last Name
Address (required)
*
Your Street Address
Your Street Address Line 2
Your City
Your State
Your Postal / Zip Code
Phone Number (required)
*
-
Area Code
Phone Number
Email
example@example.com
How would you like us to contact you?
Phone
Email
Both
Point of Contact Name:
Service Requested
With regard to the Medicare Set-Aside (MSA) reserve number: (required)
*
The MSA reserve number has already been determined.
I require assistance in determining the MSA reserve number.
Would you like to arrange professional administration of the MedicareSet-Aside (MSA) reserve?
Yes
No
What is the total of the MSA reserve number for this claim?
Would you like to arrange professional administration of the Medicare Set-Aside (MSA) reserve? (required)
*
Yes
No
Is the Claimant / Applicant currently receiving Social Security and/or Medicare benefits, or have they applied for Social Security benefits? (required)
*
Yes
No
Please verify this for me
Should we contact Medicare to determine if any liens exist?
Yes
No
Claimant Information
Claimant/Applicant Full Name (required)
*
Claimant/Applicant's Address (required)
*
Claimant/Applicant's Street Address
Claimant/Applicant's Street Address Line 2
Claimant/Applicant's City
Claimant/Applicant's State
Claimant/Applicant's Zip Code
Claimant/Applicant's Phone
-
Area Code
Phone Number
Claimant/Applicant's Date of Birth (required)
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Claimant/Applicant's Social Security Number (required)
Injury Description
Number of Injuries
1
2
3
Date of Injury #1 (required)
*
-
Month
-
Day
Year
Date
Description of Injury #1 (required)
*
Injury(ies) considered unrelated or pre-existing
*
Injury #1: Continuous Trauma? (required)
*
Yes
No
Date of Injury #2
-
Month
-
Day
Year
Date
Description of Injury #2
Injury #2: Continuous Truama
Yes
No
Date of Injury #3
-
Month
-
Day
Year
Date
Description of Injury #3
Injury #3: Continuous Trauma
Yes
No
Claim Information
Claim Type (required)
*
Workers' Compensation
Liability
Longshore
Auto
State of Jurisdiction (required)
*
Are there any underlying workers' compensation claims involved?
*
Yes
No
What is the full case value?
Is the claim settled, or has proposed settlement been reached? (required)
*
Yes
No
Unknown
Proposed Settlement Amount
Are there any Medicare liens?
Yes
No
Unknown
Total attorney fees and/or procurement costs:
Plaintiff Attorney Information
Plaintiff Attorney Full Name (required)
*
First Name
Last Name
Plaintiff Attorney Firm
Plaintiff Attorney Address (required)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Plaintiff Attorney Phone Number (required)
*
-
Area Code
Phone Number
Plaintiff Attorney Email Address (required)
*
example@example.com
Upload Documents
Upload Documents
Browse Files
Profesional Administration of the MSA Reserve: Please provide any documentation that serves as the basis for the MSA reserve amount to be administered. This information will be used to set up the professional administration account and will make onboarding more convenient for the claimant / applicant. Maximum file size 1 GB
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Special Handling
Please provide any special handling instructions as we prepare to provide the requested services:
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