MSA Submission Form

If you experience any problems or have any questions, please email newsubmissions@protocolsllc.com or call 1-800-660-7573.

Required fields denoted by *

Client Information

Primary Contact/Adjustor

Name *		Request Type MSA Recommendation Custodial Agreement DUR Rush ($375.00 additional charge)
Phone	*
Fax
Email

Primary Information

Claim Number(s) (One claim number per line)

Claim Jurisdiction

Claimant Information

Claimant Name
Gender
Address 1
Address 2
City
State
Zip
Phone

Parties to Settlement

Defense Counsel

Name
Firm
Address
Address 2
City
State
Zip
Phone
Fax
Email

Structure Broker

Name
Firm
Address
Address 2
City
State
Zip
Phone
Fax
Email

Documents

Please note to proceed with the MSA, we will need the last two (2) years of medical records, a current payment history
(e.g., Medical Cost Summary Detail) and rated age if available.

Medical Records

Payment History

Complete payment history since date of injury, showing provider name, dates of service, amount paid, CPT code, and insurance company codes.

Please send digital file in an Excel, CSV, or ASCII format.

Claim and Settlement Information

Average Weekly Wage
Current Indemnity Rate
Entitlement Term
Basis

Settlement Posture

Comments

Please list any comments regarding this case (upcoming mediations or other deadlines, claim disputes, etc.).