West Palm Beach Florida car accident Set-Aside Form Call 1-800-74-TRIAL
West Palm Beach Florida car accident claimant’s Name:
West Palm Beach Florida car accident claimant’s Date of Birth:
West Palm Beach Florida car accident claimant’s Health Insurance Claim Number:
West Palm Beach Florida car accident claimant’s Social Security Number:
West Palm Beach Florida car accident claimant’s Address and Phone Number:
West Palm Beach Florida car accident claimant’s Release Attached: ? Yes ? No
West Palm Beach Florida car accident claimant’s Counsel:
Entitlement Information (check all that applies): ? Part A ? Part B
Employer’s Information:
WC Insurer:
Claim Number:
Injury/Disease Date:
Type/Brief Description of Injury/Illness:
Total Settlement Amount:
Proposed Medicare Set-Aside Amount:
Life Expectancy:
Life-Care Plan: ? Attached ? Not Applicable
Current Medical Treatment:
Projected/Future Medical Treatment:
Recovery Prognosis:
Future Medical Amount:
Medical Attached:
Prescription Medication: