Medical Expense Management Inc. :: An insurance claim services company specializing in providing the highest level of service to our customers

Liability Referral form

*Note: All fields are required

Account Executive Information (if known)

Name:

Name of Person Entering Referral (if different from above)

Name:

Claim #:

Type of Claim (Please choose one)

Liability Insurance Auto/No-Fault Insurance

Nature of Assignment*

Medicare Set-Aside (MSA)

MSA Submission

Claimant Information
Name*:
Gender:	Male Female
Address:
City:
State
Zip Code
Phone:
DOB (xx/xx/xxxx):
SSN:
Medicare Beneficiary:	Yes No Unknown
Medicare Number (HICN#):
Social Security Disability Beneficiary:	Yes No Unknown

Account Information (Billing)*
Account Name:
Adjuster*:
Address:
City:
State
State
Phone*:
Email*:
Fax:
Claim Number:
Notes:

Claimant's Attorney

Claimant is not represented

Name:

Address:

City:

State:

Zip:

Phone:

Email:

May MedAllocators contact this person directly? Yes No

Claim Information

Proposed Settlement Amount: $
Administration of the LMSA*:	Self** Professional
Funding of the MSA:	Annuity** Lump Sum
Preferred Structured Settlement Broker:
Company:
Contact Name:
Phone:
Email:
Fax:

Defense Attorney

Employer is Not represented

Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
May we contact this person directly? Yes No

Additional Notes: