Refer an EBMSA Case

Submit this form with your case information and someone from our Client Engagement team will be in contact within one business day. We will reach out via email or phone to discuss next steps and to gather any additional information about the case.

If you have any questions please call 877-620-2221.

Your Information

First Name

Last Name

Account Name

Phone

Street Address

City

State

Zip

Claimant

First Name

Last Name

SSN

Medicare ID

Claimant Gender

Claimant DOB

Claimant Home Phone

Claimant Mobile Phone

Claimant Email

Street Address

City

State

Zip

Claim

Claim Number

Claim Type

Date of Injury

State of Jurisdiction

Rated Age

Life Expectancy

Allocation Type

Medical Allocation Amount

Indemnity Allocation Amount

Date Allocation Completed

Date Allocation Sent To CMS

Carrier Branch Office

Insurer Carrier Parent Account Name

Street Address

City

State

Zip

Payor/Insurer/Carrier/Branch

Insurer Carrier Branch Account Name

Branch Street Address

Branch City

Branch State

Branch Zip

Employer

Employer Account Name

Street Address

City

State

Zip

TPA

TPA Account Name

Street Address

City

State

Zip

Excess Carrier

Excess Carrier Account Name

Street Address

City

State

Zip

MSA Vendor

MSA Vendor Account Name

Street Address

City

State

Zip

Plaintiff Attorney

First Name

Last Name

Firm Name

Phone

Street Address

City

State

Zip

Defense Attorney

First Name

Last Name

Firm Name

Phone

Street Address

City

State

Zip

Structured Broker

First Name

Last Name

Account Name

Phone

Street Address

City

State

Zip

Files

Additional Details

Notes

Refer an EBMSA Case

Your Referral Has Been Submitted.Thank you!

Your Referral Has Been Submitted.
Thank you!