• Case Data Form

  • SETTLEMENT INFORMATION

  • **If no settlement has occurred or you are unsure, indicate gross settlement amount as $0.00

  • **Amount being placed into structured settlement annuity- can be exact amount (after fees, costs, liens, etc.) OR estimated amount. **If no settlement has occurred or you are unsure, indicate amount as $0.00

  • CLAIMANT INFORMATION

  • **If SSN is unknown, enter "0"

  • **If injured party is same as annuitant, list "Same" or "See Above."

  • PLAINTIFF COUNSEL INFORMATION

  • DEFENDANT/INSURED INFORMATION

  • **List the exact name of the insurance carrier as it will be written in the Release and/or Petition/Order (if applicable.)

  • **This may be the insurance adjuster, defense broker, etc.

  • DEFENSE COUNSEL INFORMATION

  • **Leave blank or list "N/A" if no defense attorney

  • **Leave blank or list "N/A" if no defense firm

  • MISC.

  • ** Press CTRL button while clicking to select more than one option.

Powered by

Zoho does not endorse collection of confidential information.