Case Data Form - Monarch Structured Settlements

Please complete/submit the below information to the best of your ability.

Case Type*
Date of Incident/Loss*
MM slash DD slash YYYY
Location of Incident/Loss*
Facts of Accident*
Injuries Sustained*
Gross Settlement Amount*
**If no settlement has occurred or you are unsure, indicate gross settlement amount as $0.00
Net to Client (Structure Amount)*
**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/Annuitant Name
First Last
Claimant/Annuitant DOB
MM slash DD slash YYYY
Gender*
Social Security Number*
**If SSN is unknown, enter "0"
Claimant Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claimant Phone
Claimant Email
Guardian(s) Name & Relationship (if minor child)
Injured Party (if different than Annuitant)
**If injured party is same as annuitant, list "Same" or "See Above."
First Last
Has defense/insurance carrier sent settlement check?*
Attorney Firm*
Attorney Name*
Contact Person*
**Main point of contact for email communication, coordinating settlement details, receiving structure proposals/information, etc.
Contact Person Title
Contact Person Email*
Defendant/Insured Person or Company*
Exact Name of Insurance Carrier(s)/Self-Insured(s)*
**List the exact name of the insurance carrier as it will be written in the Release and/or Petition/Order (if applicable.)
Claim Number
Defendant/Insurer Contact Person (Name and Title)
**This may be the insurance adjuster, defense broker, etc.
Insurer Contact: Phone
Insurer Contact: Email
Defense Attorney Name
**Leave blank or list "N/A" if no defense attorney
Defense Attorney Firm
**Leave blank or list "N/A" if no defense firm
Defense Attorney Phone
Defense Attorney Email
Select any/all that apply*
- All liens have been finalized (Private, Medicaid, Medicare, ERISA)
- Wish to outsource lien resolution
- Case has settled
- Client currently receives (or is applying for) SSI and/or Medicaid
- Client currently receives (or is applying for) SSDI and/or Medicare
- Client is disabled
- None of the above
Phone
This field is for validation purposes and should be left unchanged.

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