MSA Referral Form - Please complete as much of the following as possible.


CLAIMANT GENERAL INFORMATION
 

NAME
 LAST   FIRST   MIDDLE 
 
ADDRESS  
 STREET  CITY     STATE       ZIP
 
SSN  
      DATE OF BIRTH       EMPLOYER
 

EMAIL
 		  

WORKERS' COMPENSATION CARRIER INFORMATION
 

CLAIM
HANDLER
 
      CLAIM NUMBER
 

CARRIER
 		  
 
 

ADDRESS
 
 STREET    CITY     STATE     ZIP

 
PHONE  
    FAX 
 

EMAIL
 		  

ATTORNEY INFORMATION
 
CLAIMANT ATTY
 
 		 CARRIER
ATTY 		 

FIRMS
 		   FIRM  
ADDRESS
 STREET

 CITY

 STATE

 ZIP
 		 ADDRESS  STREET

 CITY

 STATE

 ZIP

PHONE
 		  
 
 		 PHONE  

FAX
 		  
 
 		 FAX  

EMAIL
 		   EMAIL  

STRUCTURE BROKER INFORMATION                                                      SETTLEMENT (COMPLETE ONLY IF SETTTLEMENT IS PENDING)
 
BROKER NAME

 
 
 

 IDEMNITY PORTION  $
FIRM

 
FUTURE MEDICAL PORTION
 		  $
ADDRESS  
 CITY

 STATE

 ZIP
 
TOTAL PRESENT VALUE
 		  $
PHONE
 
 		 Draft of Settlement Documents Available

    INCLUDE IF AVAILABLE
   


FAX
 		      

CLAIMANT MEDICAL INFORMATION
 

INJURY DATE
 		  STATE OF JURISTRICTION

DATE MAXIMUM MEDICAL IMPROVEMENT
 		  Determined By

RATED AGE
Yes , No
 		  Obtained By

CLAIMANT BENEFITS
 

CLAIMANT ON MEDICARE?       Yes , No
 

CLAIMANT RECEIVING SSD?     Yes , No
 

DATE OF SSD ELIGIBNILITY?  
 

CLAIMANT APPLIED FOR SSD?  Yes , No
 

CLAIMANT APPEALING SSD?   
 
 
Please include the following when submitting:
 
• Claim Submission Form
 
• Life Care Plan if Available
 
• Payment History
 
• Medical Records
 
• Medicare Release
 


E-Mail To:          2 + 9 = (Captcha)                  

Cambridge Galaher MSA Referral Form 01/01/2008