Referral Form Submit Documents Only Submit your referral and upload the documents after submission *Select Line of Business* No Fault Work Comp Liability * Indicates a required field Claimant Information First Name Last Name Street Address City State 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 Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Accepted Injuries Date of Injury Denied Injuries Jurisdiction 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 Jones Act USL&H Reason for Denial Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State 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 Zip Phone Number Carrier Name Employer Name Defense Attorney Information First Name Last Name Company Name Email Address Phone Number Plaintiff Attorney Information First Name Last Name Company Name Email Address Phone Number Select Requested Services Medicare Set-Aside Services Workers’ Comp MSA (WCMSA) Indemnified MSA (iMSA) Abbreviated MSA (aMSA) – With Indemnification Abbreviated MSA (aMSA) – Without Indemnification Evidence-Based MSA (eMSA) Legal Compromise MSA Standard Medical Projection Medical Cost Projection Pre-MSA Report Evaluate for Zero Allocation CMS Submission Two-Day Rush Fee Five-Day Rush Fee Conditional Payment Services Conditional Payment Verification Conditional Payment Evaluation Conditional Payment Update Dispute / Appeal Secure Final Demand / Case Closure QIC Appeal ALJ Appeal Conditional Payment (CP) Escalation Medicare Advantage / Prescription Drug Plan Lien Services Verification Lien Investigation Lien Evaluation Lien Negotiation MAP Lien Demand Medicaid Lien Services Lien Investigation Lien Evaluation Lien Negotiation Secure Final Demand Medicaid Enrollment Verification Healthcare Lien Services (TriCare, VA, ERISA, FEHBA, etc.) Lien Investigation Lien Evaluation Lien Negotiation Secure Final Lien Demand Other Services Settlement Agreement Review Legal Consulting MSP Opinion Letter Civil Money Penalty (CMP) Resolution Medical Mitigation Medicare Eligibility Verification Rated Age Benefits Coordination Social Security Disability Verification SSN / DOB Research Life Care Plan Life Care Plan Review Other: Additional Comments or Special Instructions Documents Requested for Medicare Set-Aside Services: Medical Records – Including IME, QME, and 2nd Opinions (Past 2 Years) Prescription History – Including Drug Names and Dosages (Current 2 Years) Medical Payment History & Indemnity Printouts (Current 2 Years) First Report of Injury – Including Description of Injury Proposed Lump Sum Settlement Documents (If Applicable) Applicable Legal Documents Pertaining to Compensability IMPORTANT: Completing the form does not automatically send your referral. After all required fields with the asterisk are completed, the Submit button will turn red and become active. You must click Submit for us to receive your referral. Submit Claimant Information First Name Last Name Street Address City State 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 Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Policy Limit Date of Injury Is the Policy Exhausted? Select Yes No Jurisdiction 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 Jones Act USL&H Accepted Injuries Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State 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 Zip Phone Number Select Services Conditional Payment Services Conditional Payment Verification Conditional Payment Evaluation Dispute / Appeal Conditional Payment Update Secure Final Demand / Case Closure QIC Appeal ALJ Appeal Conditional Payment (CP) Escalation Medicare Advantage / Prescription Drug Plan Lien Services Verification Lien Investigation Lien Evaluation Lien Negotiation MAP Lien Demand Medicaid Lien Services Lien Investigation Lien Evaluation Lien Negotiation Secure Final Medicaid Demand Medicaid Enrollment Verification Other Services Settlement Agreement Review Legal Consulting Civil Money Penalty (CMP) Resolution Medicare Eligibility Verification Social Security Disability Verification SSN / DOB Research Other: Additional Comments or Special Instructions Documents Requested: First Report of Loss – Including Description of Injury Declaration Page Payment Ledger Applicable Medical Records Applicable Legal Documents IMPORTANT: Completing the form does not automatically send your referral. After all required fields with the asterisk are completed, the Submit button will turn red and become active. You must click Submit for us to receive your referral. Submit Plaintiff/Injured Party Information First Name Last Name Street Address City State 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 Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Jurisdiction 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 Jones Act USL&H Date of Injury Alleged Injuries Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State 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 Zip Phone Number Carrier Name Defense Attorney Information First Name Last Name Company Name Email Address Phone Number Plaintiff Attorney Information First Name Last Name Company Name Email Address Phone Number Select Services Medicare Set-Aside (MSA) Services Liability MSA Indemnified Liability MSA (iLMSA) Legal Compromise MSA CMS Submission Two-Day Rush Fee Five-Day Rush Fee Conditional Payment Services Conditional Payment Verification Conditional Payment Update Dispute / Appeal Secure Final Demand / Case Closure QIC Appeal ALJ Appeal Conditional Payment (CP) Escalation Medicare Advantage / Prescription Drug Plan Lien Services Verification Lien Investigation Lien Evaluation Lien Negotiation MAP Lien Demand Medicaid Lien Services Lien Investigation Lien Evaluation Lien Negotiation Secure Final Demand Medicaid Enrollment Verification Other Services Settlement Agreement Review Legal Consulting MSP Opinion Letter Civil Money Penalty (CMP) Resolution Medical Mitigation Medicare Eligibility Verification Rated Age Benefits Coordination Social Security Disability Verification SSN/DOB Research Life Care Plan Life Care Plan Review Other: Additional Comments or Special Instructions Documents Requested for Medicare Set-Aside Services: Medical Records for the Past Two Years Incident Report – Including Description of Injury Proposed Settlement Documents (If Applicable) Applicable Legal Documents IMPORTANT: Completing the form does not automatically send your referral. After all required fields with the asterisk are completed, the Submit button will turn red and become active. You must click Submit for us to receive your referral. Submit
