Requestor Information |
Your Name |
|
Firm |
|
Phone # |
|
Email |
|
Services Requested(Check all that apply) |
Life Care Plan (LCP) Analysis -- Standard
Life Care Plan Analysis -- Extraordinarily Complex Critique of Opposing Life Care Plan |
Attorney Work Product? |
Yes No |
LCP Amendment? |
Yes No |
Patient/Plaintiff Information |
Name (First Last) |
* |
Address |
|
City, State ZIP |
, |
Phone |
|
Date of Birth |
* |
Gender |
Male Female
* |
Social Security # |
* |
WCAB #
(WC only) |
|
OWCP #(Longshore only) |
|
OALJ #(Longshore only) |
|
Medicare Entitled To(Check all that apply) |
A B D |
Occupation |
|
Date(s) of Injury/Illness |
*
|
Accepted Injury/Illness/Body Parts |
|
Denied/Disputed Injury/Illness/Body Parts |
|
Indicate in Notes/Special Handling section if more space is needed for dates of injuries or injury listing. |
Defendant Information (Civil/Liability Only) |
Name (First Last) |
|
Employer Information |
Employer Name (First Last) |
|
Firm |
|
Address |
|
City, State ZIP |
, |
Phone |
|
Fax |
|
Insurance Carrier/Administrator Information |
Name (First Last) |
|
Firm |
* |
Address |
|
City, State ZIP |
, |
Phone |
|
Fax |
|
Email |
|
Insurance File/Claim # |
* |
Employer Carrier/Attorney Information |
Name (First Last) |
|
Firm |
|
Address |
|
City, State ZIP |
, |
Phone |
|
Fax |
|
Email |
|
Attorney File # |
|
Applicant/Plaintiff Attorney Information |
Name (First Last) |
|
Firm |
* |
Address |
|
City, State ZIP |
, |
Phone |
|
Fax |
|
Email |
|
Structured Settlement Broker Information |
Name (First Last) |
|
Firm |
|
Address |
|
City, State ZIP |
, |
Phone |
|
Fax |
|
Email |
|
File Information |
Does the LCP need to be completed on a rush basis? |
Yes NoIf Yes, Date Due |
Is the claimant receiving Social Security Disability payments? |
Yes No Not KnownIf Yes, provide documentation. |
Has the claimant been denied Social Security Disability? |
Yes No Not Known |
Has the releases been sent to applicant/plaintiff counsel and/or claimant? |
Yes No Not Known |
Has a rated age been obtained? |
Yes No Not KnownIf Yes, provide broker information above. |
Has this claim been settled or has a settlement amount been proposed? |
Yes No Not Known
If Yes, Amount |
Additional Information |
Notes/Special Handling |
|