MEDVAL Online Referral


	*Online Referral*

TYPE OF REFERRAL

MSA Referral

Custodial Medical Account Referral

Structured Settlement Referral

REFERRING PARTY

Adjuster

Defense Attorney

Claimant Attorney

Other (please specify)

CLAIMANT INFORMATION

CLAIMANT NAME:
SSN:
Date of Birth:		MM/DD/YYYY
Address:
		City
		State Zip-Code
Phone No.:		000-000-0000
Date of Injury:		MM/DD/YYYY
ATTORNEY NAME:
Address:
		City
		State Zip-Code
Phone No:		000-000-0000

EMPLOYER INFORMATION

EMPLOYER NAME:
Address:
		City
		State Zip-Code
INSURER NAME:
Address:
		City
		State Zip-Code
Adjuster:
Phone No.:		000-000-0000
ATTORNEY NAME:
Address:
		City
		State Zip-Code
Phone No:		000-000-0000



WC Case #:
Total Settlement Amount:
Jurisdiction State:
Insurance Claim #:

Please indicate any special file handling instructions or additional claim information. Also indicate if there are any mediations, settlement con-ferences or court hearings pending and the date by which the MSA must be delivered.