Get Distribution Request Form - Continental Trust

Filling out the Distribution Request Form for Continental Trust can be a straightforward process when you have the right guidance. This form is essential for ensuring that your application is processed efficiently and accurately, assisting you in providing all necessary information.

Follow the steps to successfully complete your form.

1. Press ‘Get Form’ button to acquire the form and open it for editing.
2. Start with the Contact Information section. Here, provide your name, address, city, state, zip code, phone number, fax number, email address, social security number, date of birth, gender, marital status, education level, and any dependents you may have.
3. Next, fill in the Injury section. Specify the type of injury, diagnosis codes if known, date of last treatment, date of injury, and a description of the injury. Indicate if surgery was necessary and specify the type of surgery, if applicable.
4. Complete the Eligibility Information section by providing details about any worker's compensation claims, Medicare benefits, and private or Medicaid insurance coverage. Ensure to include all relevant policy numbers and any reported case information.
5. In the Settlement Information section, provide details about whether your case has been settled, along with the gross recovery amount and net proceeds to the client.
6. Fill out the Settlement Contact List, which includes broker information, employer details, insurer details, and attorney information. Be sure to include names, addresses, phone numbers, and relevant identification numbers.
7. Once all sections are completed and verified, save changes to your form. You can download, print, or share the form as needed to ensure it is submitted properly.

Complete your Distribution Request Form online today for timely processing.