Case Data Form

Please complete/submit the below information to the best of your ability.
  • **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
  • **If SSN is unknown, enter "0"
  • **If injured party is same as annuitant, list "Same" or "See Above."
  • **Main point of contact for email communication, coordinating settlement details, receiving structure proposals/information, etc.
  • **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.
  • **Leave blank or list "N/A" if no defense attorney
  • **Leave blank or list "N/A" if no defense firm