Legacy Claim Solutions Referral Form
What service can we assist you with today? (select all that apply)
*
Legacy Claim Resolution Service w/ Signature Valuation Program
Signature MSA Service (10 business day turnaround)
Signature RUSH MSA Service (5 business day turnaround)
Managed Care Consulting
Your Name
*
Your Email Address
*
Claimant/Applicant Name
Claimant/Applicant Gender
Please Select
Male
Female
Claimant/Applicant SSN or Medicare ID
Claimant/Applicant DOB
-
Month
-
Day
Year
Date of Injury
-
Month
-
Day
Year
Claim Number
Accepted/Denied Injuries
Claimant/Applicant Address
Street Address
Street Address Line 2
City
Please Select
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
State
Zip Code
Employer
Insurer/TPA
Adjuster Name
Adjuster Email Address
File Upload
Browse Files
Drag and drop files here
Choose a file
Please limit total file size to 10MB
Cancel
of
Submit
Should be Empty: