Flagship Services Group providing expertise with Medicare Set Asides, Section 111 and Conditional Payments
Click Here to Upload Files for Existing Referrals
Referring Company Information (*Required)
*Your Company:    
*Your First Name:   *Your Last Name:  
*Your Email:  
Please enter your complete address, if this is your first referral
*Division/Office City:   State: Zip:
Case Type (*Required)

No Fault Policy Limit:  
*State of Jurisdiction:  
Claimant Information (*Required)
*Your Claim Number:   *Injury Date (MM/DD/YYYY):  
*Insured Name:   *Insured Policy Number:  
*Claimant First Name:   Claimant Middle Name:
*Claimant Last Name:   *SSN:    
*DOB (MM/DD/YYYY):   HICN (if available):  
*Gender: MBI (if available):  
*Address:   *City:  
*State:   *Zip:  
Phone: Email:  
*Description of Injury:  
Assignment Notes:
Settlement Status:
Plaintiff Attorney' (P.A.) Information:
P.A. Company Name:
P.A. First Name: P.A. Last Name:
P.A. Phone: P.A. Email:
P.A. Address:
City: State: Zip:
Defense Attorney' (D.A.) Information:
D.A. Company Name:
D.A. First Name: D.A. Last Name:
D.A. Phone: D.A. Email:
D.A. Address:
City: State: Zip:
Supporting Documentation:
There are multiple ways to submit your supporting documentation. Please select the method you will send your supporting documentation:
Flagship Services Group,
11755 E. Peakview Ave. Suite 250
Englewood, CO 80111.
Upload Files Now!
Upload any files needed as supporting documents for this case. Please follow the easy, two step process to upload files for your referrral.
If any individual file is over 150MB, please contact Flagship for instructions at info@flagshipsgi.com after submitting your referral.

Step 1. Click the "Select and Upload Files" button to browse for the files you wish to upload.

Step 2. Click the "Submit Form" button when the referral is complete.

Flagship Services Group, Copyright 2010