CLIENT INFORMATION

Your Name*:

Your Email*: Social Security #*:

Street Address*:

City*: State*: Zip Code*:

Home Phone: Work Phone:

Cell Phone:

ATTORNEY INFORMATION

Attorney's Name*:

Firm Name*:

Paralegal/Assistant's Name*:

Street Address*:

City*: State*: Zip Code*:

Attorney's Phone: Attorney Fax:

Attorney's Email*:

Paralegal/Asst Email*:

Opposing Counsel Firm*:

Lead Council Name*:

Street Address*:

City*: State*: Zip Code*:

Amount of funds being requested*:

CASE INFORMATION

Please forward the following information with supporting documents:

Indicate which documents you are forwarding:
Copy of the ComplaintPolice ReportMedical RecordsMedical BillsClient's Insurance PolicyDefendant's Insurance Policy

Upload supporting files:

Date of Incident:

If the client was employed, please provide wage loss information) approximate total of lost wages and length of time off work), if applicable.

Brief summary of injuries and how injuries occurred:

Approximately how long were they treated (or "still being treated"):

Approximate total of related medical bills incurred to date:

Does the client have health insurance, Medicare, Medicaid, etc? If yes, please specify:

Were there witnesses? YesNo

Has the Defendant admitted liability? YesNo

Defendant's Insurance Policy Limits:

If auto accident, your client's UM policy limits and any available medical payment coverage:

Have there been any offers to settle? YesNo If yes, for how much?

What is the minimum amount you would recommend your client to settle this case for?

Besides your legal fees and costs, please list any and all other Medical Liens and/or Prior Funding Liens in relation to this case, including the company's name holding the lien and the amount of each lien (or current payoff amount to date if it is a prior funding lien):

Briefly describe your opinion of this case and any other information you believe is pertinent to this case that has not been answered above:

I do certify the information supplied by me to be true and correct.