Get Msa Allocation Case Information Accident/injury Information Public ...

Filling out the MSA Allocation Case Information Accident/Injury Information form accurately is essential for ensuring proper processing and consideration of your case. This guide provides step-by-step instructions to help you complete the form efficiently.

Follow the steps to accurately complete your case information form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Start by entering your personal information. Fill in your name, including your last name, first name, and middle initial. Provide your gender, address, city, state, and zip code. Make sure to provide a valid phone number and your date of birth along with your Social Security number.
3. Indicate whether you are a Medicare beneficiary by checking 'Yes' or 'No.' If you answered 'Yes,' provide your Medicare number. If 'No,' confirm if you will be eligible within 30 months of the settlement.
4. Provide detailed accident and injury information. Specify the type of case (Workers Compensation or Liability), the jurisdiction where the case is filed, a description of the accident, and the date of the accident.
5. Detail your injury description and any pre-existing conditions that may have an impact on your current case.
6. Confirm whether the case has settled by checking 'Yes' or 'No'. If settled, fill in the date of settlement and the gross settlement amount.
7. Complete the public benefit information section by indicating whether you or the claimant is receiving any Social Security Retirement, Social Security Disability, or Medicaid benefits, including if these benefits are expected.
8. Provide the referring party or law firm’s details: name, phone, email, firm name, address, and contact person's information.
9. Read the warranty statement thoroughly. If you agree with the stated conditions, provide your signature and the date.
10. Review all the information you’ve entered for accuracy. Once confirmed, you can save changes, download, print, or share the completed form.

Complete and submit your documents online to ensure a smooth processing of your case.