Claimant First Name:*

Last Name:*

Claimant Address:

Claimant Phone Number:

DOB:

SSN:

HICN/MBI:

Gender:* Select Gender Male Female Other

Allocation Services:

Traditional Workers’ Compensation Medicare Set-Aside (WCMSA)
Liability Medicare Set-Aside (LMSA)
Indemnified Medicare Set-Aside (iMSA)
Indemnified Liability Medicare Set-Aside (iLMSA)
Evidence Based Medicare Set-Aside (eMSA)
Legal Compromise Medicare Set-Aside (LCMSA)
Evaluate for Zero Allocation
Standard Projection
Medical Cost Projection
PreMSA
Two-Day Rush Fee (additional fees apply)
Five-Day Rush Fee (additional fees apply)
CMS Submission

Healthcare Lien Services (TriCare, VA, ERISA, and FEHBA lien, etc):

Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final Lien Demand

Other Services:

Settlement Agreement Review
Legal Consulting
MSP Opinion Letter
Medical Mitigation
Medicare Eligibility Verification
Rated Age
Benefits Coordination
Social Security Disability Verification
SSN/DOB Research
Other (Please Specify):