Follow the steps to complete the online form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the claimant's information, including their full name (last name, first and middle initial), street address, city, state, and zip code. Be sure to double-check for accuracy.
3. Input the claimant's Social Security number, date of birth, date of injury, and state of jurisdiction. These details are crucial for the processing of the claim.
4. Fill in the employer's name and address, as well as the date of hire and the claim number associated with the case.
5. Provide the referring contact information, including the attorney's name, address, phone number, and email. If applicable, include additional attorney information such as the defense attorney and their contact details.
6. Indicate the type of lien by selecting from the appropriate options (workers compensation, liability, no-fault) and answer the questions regarding the claimant's status with Medicare and Medicaid.
7. Complete the sections concerning SSDI status, total settlement amount, and the approval status of the claim. Ensure to include all accepted injuries and any disputed injuries with explanations.
8. Provide your authorization for contacting the claimant and/or attorney for any signed releases. This consent is important for the continuation of the process.
9. Once you have filled out all sections, review your entries to ensure every part is completed accurately.
10. Save your changes, and once satisfied, download the form, print it, or share it as required. Make sure to email the completed form with any signed releases to the specified address.

Complete your documents online now for efficient processing.