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
Claimant
Claim
Carrier Branch Office
Payor/Insurer/Carrier/Branch
Employer
TPA
Excess Carrier
MSA Vendor
Plaintiff Attorney
Defense Attorney
Structured Broker
Files
Additional Details

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