Case Referral Form Please complete the form below:REFERRING CONTACTName Phone Email Fax Claim # DOL Insured Underwriting Company CLAIMANTName Sex MaleFemaleDOB State of Loss/Venue LiabilityWCNon-QualifiedDEFENSE COUNSELName Phone Fax Email PLAINTIFF'S COUNSELName Phone Fax Email I would like structured settlement proposals developed with a total cost of: Please include a total annuity purchase of: and total cash, including all fees and liens, of: Forward proposals to: Referring ContactDefense CounselPlaintiff's Counsel email & faxemail onlyfax onlyCarbon copy: Referring Contact Defense CounselPlantiff's Counsel email & faxemail onlyfax onlyAdditional Comments: VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank:
