Case Information Screen Workers' Compensation
Claimant Information
Fields marked with a red asterisk mark (*) are mandatory.
* Last Name

 * First Name
* SSN (xxx-xx-xxxx)

 * Date of Birth (mm/dd/yyyy)
*Gender
Street Address
  		City:
 
State
 Zip
Claimant's Phone Number (xxx.xxx.xxxx)

 * Claim Number
* Date of Accident (mm/dd/yyyy)

 State of Jurisdiction
Employer/Defendant Name
 Employer Address
Employer Phone

 Employer City
 
State
 Zip
 
* Self-Insured
  Required Claim Information
* Carrier

 * TPA/Servicing Agent
Excess Carrier
 
  Contact Information
Who is the referring source?
Please complete all known contact information for the following:
Adjuster Name
 Phone Number
Fax Number

 Company
Email Address

Adjuster Mailing Address
Address
 City
 
State
 Zip
 
Adjuster Physical Address
Address
 City
 
State
 Zip
 
Defense Attorney
Name
 Phone Number
Fax Number

 Defense Firm
Email Address

 Address
City
  		State
Zip
 
Plaintiff/Claimant Attorney
Name
Phone Number
Fax Number

 Plaintiff/Claimant Firm
Email Address

 Address
City
  		State
Zip
 
Structured Settlement Broker
Name
Phone Number
Fax Number

 Firm
Email Address
 Address
City
  		State
Zip
 
  Service Requested: - Please call 888.MSA.PMSI (888.672.7674) with any questions.
Social Security Verification Only - PMSI Settlement Solutions will determine whether the Claimant/Applicant is a Medicare/Social Security beneficiary. (Requires SS Release)
  Yes No
MSA requested upon verification of SS benefits?
Medicare Set-Aside Allocation Only* 
  Yes No
DVR with MSA (Drug VALUE Review)
 Rush service available for an additional charge.
 Rush needed?                         5-Day   2-Day        
Future Medical Cost Projection (FMCP) Only*
 
  Yes No
FMCP with MSA
Maryland Non Beneficiary FMCP
 
  Yes No
  Yes No
Was Prior MSA completed by Settlement Solutions?
Conditional Payment Verification
Conditional Payment Analysis
Medical Reserve Forecast
  Notes:
(Please include any information related to this file not otherwise noted.)
 
   
Pertinent Information Related to the File:
* What diagnoses/body part(s) are accepted in this claim?
What diagnoses/body part(s) are denied/disputed in this claim?  
What is the proposed settlement amount?  
Unless otherwise indicated, the referring party will be responsible for all payments.
*Cancellation of MSA or FMCP after work has commenced is subjected to a fee of $1,300.
If you would like an email confirmation, please enter your email address below. If you would like to send to multiple email addresses, please enter each address separated by a semi-colon. If you have already provided an email address in the Adjuster Contact Information section of this form, you will automatically receive an email confirmation.
Confirmation Email
Please indicate the PMSI Settlement Solutions Associate that worked with you on this file: