Receive a Settlement Plan "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Name*Date of Birth:* Month Day Year Social Security Number or Tax ID Number:Address*Phone*Email* PUBLIC ASSISTANCE BENEFITSPLEASE PROVIDE THIS INFORMATION BYINCIDENT DETAILSOverview of Physical InjuriesNo Physical InjuriesSETTLEMENT DETAILSGross SettlementCompany paying the settlementNet Settlement or Approximate AmountIf there are multiple companies paying, please list each company and the amount they are payingDoes the company require us to co-broker the structured settlement? Please provide their contact informationSETTLEMENT PARTIESProbate Attorney or Guardian ad Litem (if applicable)Defense AttorneyDOCUMENTS - IF AVAILABLEProof of Birth Document (Driver's License, Birth Certificate, or Passport)Guardianship documents, POA (if applicable)Life Care Plan and recent medicals (if applicable)MEDIATION/MEETINGS/HEARING/OTHER DATESNOTES
