Structured Settlement Referral Form Claimant Name: Injury: Date of Birth: Claimant Gender: Male Female Email: Email: CLAIMANT COUNSEL INFORMATION Name: Phone Number: BASIC CLAIM INFORMATION CLAIMS PROFESSIONAL INFORMATION Name: Phone Number: DEFENSE COUNSEL INFORMATION • Copy of MSA Report (if applicable) • Copy of CMS approval (if applicable) KMUNOZ@TEAMARCADIA.COM Send completed form and any relevant documents to KMUNOZ @teamarcadia.com Jurisdiction : Claim Number: Alleged Date of Injury : CLAIMANT INFORMATION Name: Phone Number: Email: ALLEGED ACCIDENT DESCRIPTION Please also include the following in your referral: • A few recent medical reports from the last 2–3 years and the most recent med-legal report (if one has been completed). Insured: Underwritting Company: For questions or additional help, contact me: Book a meeting 407.435.5642 l l