Case Referral Form – UK Office

Referring Contact
Defense Counsel
Name:
Name:
Phone:
Phone:
Email:
Fax:
Fax:
Email:
Claim#:
DOL:
Insured:
Underwriting Company:
Claimant:
Plaintiff's Counsel
Name:
Name:
Sex:
Phone:
DOB:
Fax:
State of Loss/Venue:
Email:
Liability WC Non-Qualified


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 Contact Defense Counsel Plaintiff’s Counsel
Carbon copy: Referring Contact Defense Counsel Plaintiff’s Counsel
Additional Comments:


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