Fixed Percentage Option Election - Franco Signor 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the liability insurance settlement amount in the designated field. This is crucial as it sets the basis for your fixed payment option.
3. Next, specify your payment amount, which should be 25% of the total settlement. Ensure this figure is accurate to avoid any discrepancies.
4. Fill in your personal details including Beneficiary Name, Date of Incident, Medicare Number, and Date of Settlement. These fields are essential for processing your election.
5. Provide a brief description of your injuries in the space provided. Be concise yet thorough to ensure clarity.
6. Review the certification statements carefully and confirm that they apply to your situation by checking the appropriate boxes.
7. Indicate whether you are including a check or money order for payment or if you will pay upon receiving a bill. Fill in the relevant amounts as necessary.
8. If applicable, check if you are signing on behalf of a beneficiary and ensure you have submitted valid proof of representation.

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