Case Data Form - Monarch Structured Settlements

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

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Case Type*

Date of Incident/Loss*

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

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