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This page allows you to enter additional beneficiary or claimant information for a new case. When data is pre-populated on this page, the system does NOT allow the values in those fields to be changed. If any pre-populated values are incorrect, cancel the case’s creation and click on the Create a New Case link to start over.
For Self account types: If the name, address, or phone number information is no longer correct, click the Cancel Case Creation button, make the necessary corrections via the Update Personal Information screen, then create a new case.
Fields marked with a superscript 1 (1) are required.
| Last Name | Displays the beneficiary/claimant’s last name. |
| First Name | Displays the beneficiary/claimant’s first name. |
| MI | Displays the beneficiary/claimant’s middle initial, if previously entered. |
| Beneficiary Medicare ID | Displays the beneficiary/claimant’s Medicare ID, if previously entered. The first 5 digits are masked with asterisks. |
| Beneficiary/Claimant SSN | Displays the beneficiary/claimant’s social security number, if previously entered. The first 5 digits are masked with asterisks. |
| Beneficiary/Claimant Date of Birth | Displays the beneficiary/claimant’s birth date. |
| Beneficiary/Claimant Gender | Displays the beneficiary/claimant’s gender. |
| Address Line 1 | Enter the first line of the beneficiary/claimant’s mailing address. Note:This field is pre-populated for Self Account types. |
| Address Line 2 | Enter the second line of the beneficiary/claimant’s mailing address. Optional. Note:This field is pre-populated for Self Account types, if previously entered. |
| City | Enter the city where the beneficiary/claimant lives. Note:This field is pre-populated for Self Account types. |
| State of Residence | Select the state where the beneficiary/claimant lives from the dropdown list. Note: This field is pre-populated for Self Account types. |
| Zip Code | Enter the beneficiary/claimant’s 5-digit zip code. The ZIP+4 field is optional. Note:This field is pre-populated for Self Account types. |
| Phone | Enter the beneficiary/claimant’s telephone number. The extension field is optional. Note:This field is pre-populated for Self Account types. |
| State where injury occurred | Select the state where the beneficiary/claimant’s initial injury occurred from the dropdown list. |
| Submitter Type | Select a submitter type from the dropdown list. This field is not displayed for Self account types. Beneficiary/Claimant Representative Claimant Attorney Defendant Attorney WC Carrier Employer Medical Consultant Other |
Click the Next button to save all information entered up to this point and proceed to the next Case Information page.
Click the Case Summary button to view a synopsis of the case information entered.
For new cases and cases in Work-In-Progress (WIP) status:
Click the Save Work-In-Progress button to save all information entered up to this point. You can return to the WCMSAP at a later time to complete the case creation process.
Click the Cancel Case Creation button to delete all information entered and cancel out of the case creation process.
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