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Step
1
of
5
- Plaintiffs Attorney
20%
Plaintiff`s Attorney Information
Law Firm Name
Contact Person
Email
Phone
Status of Claim: Is case in suit?
Yes
No
Please provide the Cause Number:
Patient Information
Name
Date of Birth
MM slash DD slash YYYY
Phone
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Is this an automotive accident?
Yes
No
Plaintiff's auto insurance carrier (auto collisions only)
UM/UIM?
Yes
No
Limit
PIP/MED PAY
Yes
No
Limit
Medical Treatment and Bills to Date:
Are there any imaging reports or records?
Yes
No
if yes, please attach
Drop files here or
Select files
Max. file size: 300 MB.
Provider
Total Charges
Lien
Yes
No
Provider
Total Charges
Lien
Yes
No
Provider
Total Charges
Lien
Yes
No
Provider
Total Charges
Lien
Yes
No
Does Plaintiff have health insurance?
Yes
No
Approximate Amount
Does Plaintiff have child support liens?
Yes
No
Approximate Amount
Does Plaintiff have legal funding liens?
Yes
No
Approximate Amount
Prior Medical Treatment/Claim
Has the Plaintiff ever filed an injury claim in the past?
Yes
No
Please describe (date of injury, motor vehicle accident, worker’s comp claim)
Please list all pre-existing medical conditions (list treatment dates):
Incident Information
Is there a police report?
Yes
No
If yes, please attach copy
Max. file size: 25 MB.
Maximum File Size: 25MB
Has the third party carrier accepted liability?
Yes
No
Date of Injury
Month
Day
Year
Type of Claim
Auto
Premises
Liability
Description of Event
Location of the Event
Description of Injuries
Property damage paid by 3rd party carrier?
Yes
No
If yes, how much?
Defendant Information
Defendant Name
Insurance Company
Claim Number
Policy Limits
Has the insurance company made an offer?
Yes
No
if yes, amount
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