GARRISON

GARRISON

CASE REFERRAL FORM

PLAINTIFF COUNSEL

ADJUSTER

Attorney’s Name:

Name:

Firm Name:

Phone Number:

Address:

Email:

Phone Number:

Claim Number:

Email:

Carrier Paying Claim:

Type of Claim:

Liability

UM

UIM

WC

N/A

Date of Loss: State of Loss: Name of Insured:

ANNUITANT

DEFENSE COUNSEL

Name:

Attorney’s Name:

Male

Female

N/A

Firm Name:

Date of Birth:

Address:

Social Security Number:

Phone Number:

Address:

Email:

Nature of Injury:

I would like structured settlement proposals developed with a total cost of: N/A

Attorney Fees:

N/A Liens:

N/A

Cash at Settlement:



Structured Settlement Annuity Cost: Please send proposals to:

Defense Counsel

Plaintiff Counsel

Adjuster

Please carbon copy:

Defense Counsel

Plaintiff Counsel

Adjuster

Additional Comments:

10105 E. Via Linda, Suite 103, Scottsdale, Arizona 85258 • Phone (844) 222-0020 • Fax (480) 222-7075

www.garrisonsettlements.com