<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"]

[text your-state class:suba placeholder "STATE"]

[text your-zip class:suba placeholder "ZIP CODE"]

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

[text* your-phone class:suba placeholder "PHONE NUMBER"]

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

<p>I am The : </p>

[select Iamthe class:suba "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"]

[text claimant-state class:suba placeholder "CLAIMANT STATE"]

[text claimant-zip class:suba placeholder "CLAIMANT ZIP"]

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

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


[text date-injur 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 class:wokaa use_label_element "SSDI Beneficiary"]
[text 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 class:wokaa 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"]
[text employer-satate class:suba placeholder "EMPLOYER STATE"]
[text employer-zip class:suba placeholder "EMPLOYER ZIP CODE"]
[text employer-phone class:suba 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"]
[text ClaimantAttorney-state class:suba placeholder "CLAIMANT ATTORNEY STATE"]
[text ClaimantAttorney-zip class:suba placeholder "CLAIMANT ATTORNEY ZIP CODE"]
[text ClaimantAttorney-email class:suba placeholder "CLAIMANT ATTORNEY EMAIL ADDRESS"]
[text ClaimantAttorney-phone class:suba placeholder "CLAIMANT ATTORNEY PHONE NUMBER"]
[text 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"]
[text adjuster-state class:suba placeholder "ADJUSTOR STATE"]
[text adjuster-zip class:suba placeholder "ADJUSTOR ZIP CODE"]
[text adjuster-email class:suba placeholder "ADJUSTOR EMAIL ADDRESS"]
[text adjuster-phone class:suba placeholder "ADJUSTOR PHONE NUMBER"]
[text 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"]
[text deffenseattorney-state class:suba placeholder "DEFENSE ATTORNEY STATE"]
[text deffenseattorney-zip class:suba placeholder "DEFENSE ATTORNEY ZIP CODE"]
[text deffenseattorney-email class:suba placeholder "DEFENSE ATTORNEY EMAIL ADDRESS"]
[text deffenseattorney-phone class:suba placeholder "DEFENSE ATTORNEY PHONE NUMBER"]
[text 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>

[checkbox checkbox-496 class:wokaa "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-497 class:wokaa "Calculate MSA Allocation: Includes medical treatment chronology, future medical cost and drug cost tables based on rated age life expectancy, table of non-Medicare covered medical services, structured annuity quote."]

[checkbox checkbox-498 class:wokaa "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:wokaa "Submit proposed MSA to CMS: Submission of completed MSA and supporting documentation to CMS for approval. Claimant's signed Consent Form required."]


[checkbox checkbox-500 class:wokaa "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."]

[checkbox checkbox-501 class:wokaa " Expedited Service: completion of MSA Allocation within 5 business days of receipt of the necessary records (additional fee applies)."]

[checkbox checkbox-502 class:wokaa "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:wokaa "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:wokaa "Request for CMS approval of Waiver of MSA ($0 MSA): Additional documentation may be required. Claimant's signed Consent Form required."]

[checkbox checkbox-505 class:wokaa "Medical Cost Projection: For valuing claim and setting reserves - does not include MSA analysis. Release forms not required. Option to convert to MSA available."]

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

[checkbox checkbox-507 class:wokaa "Onsite Copy/Scanning: Copy requests should be submitted 24 hours in advance of the appointment day to allow us time to coordinate your service request."]



[submit class:btn-submit "SUBMIT"]
1
Manley & Associates "Workers Compensation Claim" Form Submission
[your-name] <wordpress@manleyandassociates.com>
nformisano@bmanleymsa.com
From: [your-name] <[your-email]>

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

Full name: [your-name]

Firm name" [your-firm]

Mailing Address: [your-address]

City: [your-city]

State: [your-state]

Zip: [your-zip]

Email Address: [your-email]

Phone Number: [your-phone]

Fax: [your-fax]

I am the: [Iamthe]

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

Claimant's name: [claimant-name]

Gender: [gender]

Claim File Number: [claim-file]

Claimant Address: [claimant-add]

Claimant City: [claimant-city]

Claimant State: [claimant-state]

Claimant Zip: [claimant-zip]

Date of Birth: [d-ob]

Social Security Number: [social-sn]

All Dates of Injuries to be included in the MSA and Settlement: [dates-injur]

State of Jurisdiction: [state-oj]

SSDI Beneficiary? [SSDIBeneficiary]

Date Medicare Eligible: [date-medi]

Settlement Agreement: [settlement-agreement]

Non-covered Body Parts and Conditions: [non-cover]

Covered Body Parts and Conditions: [cover]

Brief description of injury: [brief-des]

Gaurdian Appointed? [GuardianAppointed]

Other comments: [Othercomments]

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

Employer: [employer-name]

Employer Address: [employer-add]

Employer City: [employer-city]

Employer State: [employer-satate]

Employer Zip: [employer-zip]

Employer Phone: [employer-phone]

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

Claimant Attorney Name: [ClaimantAttorney-name]

Claimant Attorney Firm: [ClaimantAttorney-firm]

Claimant Attorney Address: [ClaimantAttorney-add]

Claimant Attorney City: [ClaimantAttorney-city]

Claimant Attorney State: [ClaimantAttorney-state]

Claimant Attorney Zip: [ClaimantAttorney-zip]

Claimant Attorney E-mail: [ClaimantAttorney-email]

Claimant Attorney Phone: [ClaimantAttorney-phone]

Claimant Attorney Fax: [ClaimantAttorney-fax]

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

Adjuster Name: [adjuster-name]

Adjuster Firm: [adjuster-firm]

Adjuster Address: [adjuster-add]

Adjuster City: [adjuster-city]

Adjuster State: [adjuster-state]

Adjuster Zip: [adjuster-zip]

Adjuster E-mail: [adjuster-email]

Adjuster Phone: [adjuster-phone]

Adjuster Fax: [adjuster-fax]


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

Defense Attorney Name: [deffenseattorney-name]

Defense Attorney Firm: [deffenseattorney-firm]

Defense Attorney Address: [deffenseattorney-address]

Defense Attorney City: [deffenseattorney-city]

Defense Attorney State: [deffenseattorney-state]

Defense Attorney Zip: [deffenseattorney-zip]

Defense Attorney Email Address: [deffenseattorney-email]

Defense Attorney Phone: [deffenseattorney-phone]

Defense Attorney Fax: [deffenseattorney-fax]

<h3 class="heading3">AVAILABLE SERVICES</h3>
<p>All checked boxes for the requested services:<br>
[checkbox-496]
[checkbox-497]
[checkbox-498]
[checkbox-499]
[checkbox-500]
[checkbox-501]
[checkbox-502]
[checkbox-503]
[checkbox-504]
[checkbox-505]
[checkbox-506]
[checkbox-507]

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Manly & Associate "[your-subject]"
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