<h3 class="heading3">YOUR INFORMATION</h3>

[text* your-name class:suba placeholder "FULL NAME"]

[text your-firm class:suba placeholder "FIRM NAME"]

[text your-address class:suba placeholder "MAILING ADDRESS"]

[text your-city class:suba placeholder "CITY"]


[select your-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number your-zip min:5 class:sub placeholder "ZIP CODE"]

[email your-email class:suba placeholder "EMAIL ADDRESS"]

[number your-phone class:digits placeholder "PHONE NUMBER"]

[number your-fax class:suba placeholder "YOUR FAX"]

<p>I am The : </p>

[select Iamthe class:suba "-- Select --" "Claimant's Attorney" "Adjuster" "Defense Attorney"]


<h3 class="heading3">CLAIMANT</h3>


[text* claimant-name class:suba placeholder "CLAIMANT NAME"]

<p>Gender: </p>
[select* gender class:suba "Male" "Female"]

[text claim-file class:suba placeholder "CLAIM FILE NUMBER"]

[text claimant-add class:suba placeholder "CLAIMANT ADDRESSS"]

[text claimant-city class:suba placeholder "CLAIMANT CITY"]


[select claimant-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]



[number claimant-zip min:5 class:sub placeholder "CLAIMANT ZIP"]

[text d-ob class:suba placeholder "DATE OF BIRTH"]

[text social-sn class:digits placeholder "SOCIAL SECURITY NUMBER"]


[text social-snn class:suba placeholder "ALL DATES OF INJURIES TO BE INCLUDED IN THE MSA AND SETTLEMENT"]
[text state-oj class:suba placeholder "STATE OF JURISDICTION"]
[checkbox SSDIBeneficiary use_label_element "SSDI Beneficiary"]
[date date-medi class:suba placeholder "DATE MEDICARE ELIGIBLE"]
[text settlement-agreement class:suba placeholder "SETTLEMENT AGREEMENT: $"]
[text non-cover class:suba placeholder "NON-COVERED BODY PARTS AND CONDITIONS"]
[text cover class:suba placeholder "COVERED BODY PARTS AND CONDITIONS"]
[text brief-des class:suba placeholder "Brief description of injury (examples: fell down stairs, lifting heaving box, car accident, etc.)"]
[checkbox GuardianAppointed use_label_element "Guardian Appointed"]
[textarea Othercomments class:suba placeholder "Other comments"]

<h3 class="heading3">EMPLOYER</h3>
[text employer-name class:suba placeholder "EMPLOYER"]
[text employer-add class:suba placeholder "EMPLOYER ADDRESS"]
[text employer-city class:suba placeholder "EMPLOYER CITY"]
[select employer-satate class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]


[number employer-zip min:5 class:sub placeholder "EMPLOYER ZIP CODE"]
[number employer-phone class:digits placeholder "EMPLOYER PHONE NUMBER"]

<h3 class="heading3">CLAIMANT ATTORNEY</h3>
[text ClaimantAttorney-name class:suba placeholder "CLAIMANT ATTORNEY NAME"]
[text ClaimantAttorney-firm class:suba placeholder "CLAIMANT ATTORNEY FIRM"]
[text ClaimantAttorney-add class:suba placeholder "CLAIMANT ATTORNEY ADDRESSS"]
[text ClaimantAttorney-city class:suba placeholder "CLAIMANT ATTORNEY CITY"]
[select ClaimantAttorney-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number ClaimantAttorney-zip min:5 class:sub placeholder "CLAIMANT ATTORNEY ZIP CODE"]
[email ClaimantAttorney-email class:suba placeholder "CLAIMANT ATTORNEY EMAIL ADDRESS"]
[number ClaimantAttorney-phone class:digits placeholder "CLAIMANT ATTORNEY PHONE NUMBER"]
[number ClaimantAttorney-fax class:suba placeholder "CLAIMANT FAX NUMBER"]

<h3 class="heading3">ADJUSTOR</h3>
[text adjuster-name class:suba placeholder "ADJUSTOR NAME"]
[text adjuster-firm class:suba placeholder "ADJUSTOR FIRM"]
[text adjuster-add class:suba placeholder "ADJUSTOR ADDRESS"]
[text adjuster-city class:suba placeholder "ADJUSTOR CITY"]
[select adjuster-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number adjuster-zip min:5 class:sub placeholder "ADJUSTOR ZIP CODE"]
[email adjuster-email class:suba placeholder "ADJUSTOR EMAIL ADDRESS"]
[number adjuster-phone class:digits placeholder "ADJUSTOR PHONE NUMBER"]
[number adjuster-fax class:suba placeholder "ADJUSTOR FAX NUMBER"]

<h3 class="heading3">DEFENSE ATTORNEY</h3>

[text deffenseattorney-name class:suba placeholder "DEFENSE ATTORNEY NAME"]
[text deffenseattorney-firm class:suba placeholder "DEFENSE ATTORNEY FIRM"]
[text deffenseattorney-address class:suba placeholder "DEFENSE ATTORNEY ADDRESS"]
[text deffenseattorney-city class:suba placeholder "DEFENSE ATTORNEY CITY"]
[select deffenseattorney-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "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	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number deffenseattorney-zip min:5 class:sub placeholder "DEFENSE ATTORNEY ZIP CODE"]
[email deffenseattorney-email class:suba placeholder "DEFENSE ATTORNEY EMAIL ADDRESS"]
[number deffenseattorney-phone class:digits placeholder "DEFENSE ATTORNEY PHONE NUMBER"]
[number deffenseattorney-fax class:suba placeholder "DEFENSE ATTORNEY FAX NUMBER"]

<h3 class="heading3">AVAILABLE SERVICES</h3>
<p>Please check all appropriate boxes below for the requested services. <br>

Fees for services are due upon completion of the assignment. An invoice will be sent with the final report. If your case proves unusually complex and requires large expenditures of time beyond what is customary and reasonable, there may be an additional charge. We will communicate with you prior to applying this charge.</p>
<hr>
[checkbox checkbox-497 class:suba "Calculate MSA Allocation: Includes medical treatment chronology, future medical cost and drug cost tables based on rated age life expectancy, structured annuity quote."]

[checkbox checkbox-505 class:suba "Medical Cost Projection: For valuing claim and setting reserves - does not include MSA analysis. Release forms not required. Option to convert to MSA available."]
<hr>
[checkbox checkbox-496 class:suba "Determine Medicare status: Includes verification thru SSA inquiry of Insured's SSDI and Medicare status and legal opinion regarding whether or not a MSA is recommended. Claimant's signed SSA release form is required."]

[checkbox checkbox-506 class:suba "Drug Utilization Review: Includes referral to a pharmacist for drug regimen review and recommendations."]

[checkbox checkbox-498 class:suba "Medicare Recovery Claim Research: Includes inquiries to CMS to obtain conditional payment information; requires Carrier's signed Proof of Representation or Claimant's signed Consent Form."]

[checkbox checkbox-499 class:suba "Submit proposed MSA to CMS: Submission of completed MSA and supporting documentation to CMS for approval. Claimant's signed Consent Form required."]
<hr>
[checkbox checkbox-500 class:suba "Complete MSA Bundle: Includes verification of Claimant's SSDI and Medicare status, completion of MSA, conditional payment research, submission of MSA to CMS for approval. Claimant's signed Consent Form and SSA Release are required."]
<hr>
[checkbox checkbox-501 class:suba " Expedited Service: completion of MSA Allocation within 5 business days of receipt of the necessary records (additional fee applies)."]
<hr>
[checkbox checkbox-502 class:suba "Revision of MSA: Includes review of medical records, pharmacy summary, payment history since the most recent records provided for original MSA; updated tables based on current pricing and life tables; new rated age if appropriate."]

[checkbox checkbox-503 class:suba "Compromise of Medicare's Conditional Payment: Includes legal argument to support request for reduction or waiver of CMS conditional payment recovery claim; Claimant's signed Consent Form required. Hourly charges applied."]

[checkbox checkbox-504 class:suba "Request for CMS approval of Waiver of MSA ($0 MSA): Additional documentation may be required. Claimant's signed Consent Form required."]
<hr>


[submit class:btn-submit "SUBMIT"]