INTAKE FORM FOR LIABILITY AND WORKER'S COMPENSATION SETTLEMENTS

PLEASE COMPLETE THIS FORM TO THE BEST OF YOUR ABILITY. THE MORE INFORMATION YOU SUPPLY, THE MORE ACCURATE AND COMPLETE OUR INITIAL ANALYSIS CAN BE. THIS FORM IS BEING CREATED AND WILL BE SUBMITTED OVER A SECURE SSL CONNECTION, PROTECTED BY 128 BIT ENCRYPTION. YOUR INFORMATION WILL NOT BE SHARED WITH ANYONE WITHOUT YOUR EXPRESS PERMISSION.

1. Please provide the name, address, telephone number and e-mail address of the person completing this questionnaire:

Name:

Address:

City: State: Zip Code:

Area Code and Telephone Number:

E-mail Address:

2. What is the nature of the claim being settled?

(Please check one) Third Party Liability Worker’s Compensation Both

If the claim being settled is a Worker’s Compensation claim, please remember that Medicare applies a set of criteria to any Worker’s Compensation settlement on a case-by-case basis in order to determine whether Medicare has an obligation for services provided after the settlement that originally were the responsibility of the workers’ compensation carrier. Each case is different because the facts of each case are different. Medicare must be given complete and credible documentation and information.

3. What is the plaintiff or claimant/applicant’s:

Name:

Address:

City: State: Zip Code:

Area Code and Telephone Number:

Marital Status: M S

Social security number: Date of Birth:

(We will not supply your Social Security Number or other contact information to any third parties without your permission.)

4. List the names and birthdates of any Minor Children of the plaintiff or claimant/applicant:

5. What was the date of injury?

6. In which state did the injury occur?

7. How did the injury occur?

8. Describe the nature of injury and how is the plaintiff or claimant/applicant doing today?

9. Has the plaintiff or claimant/applicant reached maximum medical improvement?

YES NO DON'T KNOW

10. On what date did the plaintiff or claimant/applicant reach maximum medical improvement (if not known, enter "unknown")?

11. Where does the plaintiff or claimant/applicant live (e.g., at home, in a nursing home, another facility)?

12. With whom does the plaintiff or claimant/applicant live?

13. What is the plaintiff or claimant/applicant’s chronological age?

Rated age (if not known, enter "unknown")?

14. What is the chronological age of the spouse of the plaintiff or claimant/applicant (if not known, enter "unknown")?

15. Is the plaintiff or claimant/applicant mentally competent to enter into a settlement?

YES NO DON'T KNOW

16. Is there more than one plaintiff or claimant/applicant ? YES NO

If yes, list names of additional plaintiff or claimant/applicant(s).

17. List the nature of claims for additional plaintiff or claimant/applicant(s).

18. If the plaintiff or claimant/applicant is a parent, does he or she have reimbursable costs?

YES NO N/A

19. What is the name, address, city, state and zip code of the defendant?

Name:

Address:

City: State: Zip Code:

20. List the name of the defendant’s insurance carrier; the name, address and telephone of the agent or claim’s adjuster assigned to this case; and the insurance carrier’s claim number for this case.

Insurance Carrier Name:

Adjuster Name:

Address:

City: State: Zip Code:

20. What is the name, address and telephone number of the attorney for the defendant and/or the defendant’s insurance carrier?

Name:

Address:

City: State: Zip Code:

21. How much is the overall settlement?

22. Is this settlement a compromise or a full commutation?

Compromise Full Commutation Don't Know

23. How is the settlement being paid (include lump sum amount(s) and date(s), as well as information on the amounts and dates of any structured settlement payments)?

24. What are the costs?

25. What will be owed to your PI/WC attorney in fees?

26. Are fees owed to more than one lawyer? YES NO

27. Will there be any attorney liens filed in the case? YES NO DON'T KNOW

28. How is the settlement being apportioned? (If this is a Worker’s Compensation case, how much is being apportioned to indemnity and how much is being apportioned to future and/or past medicals?

29. If this is a Workers’ Compensation case, is the settlement amount for future medical expenses based upon actual full dollar amounts or Workers’ Compensation schedule amounts?

Full Dollar Amounts WC Schedule Amounts Don't Know

30. Has the plaintiff or claimant/applicant received Medicaid at any time since the accident and prior to the settlement?

YES NO DON'T KNOW

31. Has the plaintiff or claimant/applicant received Medicare at any time since the accident and prior to the settlement?

YES NO DON'T KNOW

32. Has Medicaid or Medicare been notified of the settlement, arbitration award or jury verdict?

YES NO DON'T KNOW

33. Is there a Medicaid lien or Medicare claim? YES NO DON'T KNOW

34. Are there any insurance subrogation claims in the case? YES NO DON’T KNOW

If yes, how much and to whom?

35 Are there any other liens, such as hospital liens? YES NO DON’T KNOW

If yes, how much and to whom?

36. Has a conservator, guardian or guardian ad litem been appointed for the plaintiff or claimant/applicant?

YES NO DON'T KNOW

37. Is court approval of the settlement necessary?

YES NO DON’T KNOW

38. If court approval of the settlement is necessary, please state the reasons why.

39. Assuming court approval is necessary, who are the interested parties? (Please provide names and addresses of interested parties.)

40. Is anyone in the plaintiff or claimant/applicant’s household or immediate family receiving public benefits (e.g., Medicaid, special waiver programs, SSI, SSDI, Medicare, etc.)?

YES NO DON’T KNOW

If yes, what public benefits?

41. Is the plaintiff or claimant/applicant eligible for Medicare? YES NO DON’T KNOW

If yes, since when?

42. Is the plaintiff or claimant/applicant eligible for SSDI or SSI?

SSDI SSI BOTH DON'T KNOW

If plaintiff or claimant/applicant is eligible for SSDI or SSI, since when?

43. If the plaintiff or claimant/applicant is not eligible for SSDI or SSI, has an application been filed?

YES NO DON'T KNOW N/A

If yes, has there been an initial determination of eligibility by Social Security?

YES NO DON'T KNOW N/A

If yes, has an appeal been filed and what is the status of that appeal?

YES NO DON’T KNOW N/A

Status of Appeal:

44. What other public benefits is the plaintiff or claimant/applicant receiving? (Please list all public benefits; i.e., Medicaid, special waiver programs, etc. If you do not know, enter "unkown.")

45. With regard to each public benefit program for which the plaintiff or claimant/applicant is eligible, please give the date(s) the claimant became eligible:

46. Is it likely plaintiff or claimant/applicant will require public benefits assistance in the future?

YES NO DON’T KNOW

47. Does the plaintiff or claimant/applicant have any income? YES NO DON'T KNOW

If yes, please state the monthly amount(s) and from what source(s)?

48. Has someone made an application for public benefits that is still pending?

YES NO DON’T KNOW

49. In 10 states plus the District of Columbia, the carrier takes the offset in Worker’s Compensation cases and the claimant’s Social Security will not be affected by the settlement. In the remaining states, the settlement could cause the claimant to lose his or her Social Security entirely if the monies apportioned to indemnity are not carefully thought through before being apportioned. If indemnity benefits are being paid, who is currently taking the offset, the carrier or Social Security?

Carrier Social Security Don't Know

50. What services does the plaintiff or claimant/applicant now need that the claimant is not receiving?

51. What equipment or personal property does the plaintiff or claimant/applicant hope to purchase with this settlement?

52. What are the plaintiff or claimant/applicant’s reasons for wanting to settle at this time?

Once you have completed the above questionnaire, please complete the following additional sections before you submit your answers:

When we receive a completed questionnaire, we will contact you by fax or e-mail to provide you with contact information for send the additional documentation we will need for a thorough review of your case (e.g., a life care plan, Medicare Set-Aside allocation report, independent medical exam report, or copies of medical records summarizing your injuries, treatment, current condition and projections for future care needs; and the claims payment history from the insurance carrier). Please provide an e-mail address or fax number (including area code) where we can contact you for this additional information:

We will need to schedule a telephone conference of approximately 1/2 to 1 hour. We will call you. Please provide the best telephone number (including area code) to contact you to schedule this appointment:

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