*Denotes required information.

Rush Service Request

Service Being Requested

Case Classification

Adjuster Information

• Referring Party Name
• Referring Party Address *
• Referring Party Address Line 2
• City

  State / Province / Region 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 Puerto Rico United States Minor Outlying Islands Virgin Islands
• Postal / Zip Code

  Country Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombi Comoros Congo (Brazzaville) Congo Costa Rica Cote d\'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepa Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togooption> Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
• Referring Party Phone *
• Referring Party Email *
• Preferred Structure Settlement Broker

Referring Party Information

• Claimant Name *
• Date of Injury *

  Claim Number
• Claimant Address
• Claimant Address Line 2
• City

  State/Providence/Region 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 Puerto Rico United States Minor Outlying Islands Virgin Islands
• Jurisdiction

  Postal / Zip Code
• Claimant Social Security Number *

  Claimant Date of Birth *
• Claimant Employer
• Claimant Employer Address
• Claimant Employer Phone Number
• Defense Counsel's Contact Information
• Claimant's Counsel's Contact Information

Claimant Case Information

• How did injury occur?
• Are there any denied conditions?

  Yes

  No

• List of denied conditions
• What was the specific nature of the accepted injury?
• Please give title and brief description of the Claimants job at the time of injury.
• Is Claimant currently receiving Social Security Disability benefits?

  Yes

  No

• Is Claimant currently eligible to receive Medicare benefits?

  Yes

  No

• What is the total amount of indemnity benefits paid to date?
• Has a settlement been reached?

  Yes

  No

  Please provide the estimated medical settlement amount.
• Tentative Settlement Range
• How is set aside to be paid?

  Out of settlement proceeds

  Above and beyond settlement proceeds