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Step 1 of 4 - Plaintiffs Attorney

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Plaintiff`s Attorney Information
Firm Name
Contact Person
Email
Phone
Handling Attorney
Handling Attorney Email
Status of Claim: Is case in suit?
- Yes
- No
Please provide the County Cause Number:

Patient Information
Name
Date of Birth
Month
Day
Year
Phone
Address
City
State
Zip
Medical Treatment and Bills to Date:
Are there any imaging reports or records?
- Yes
- No
if yes, please attach
Drop files here or

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

Date of Injury
Month
Day
Year
Describe Injuries
Treatment is needed for:
Doctor(s) requested:
Type Of Claim:
- Auto Collision
- Premises Liability
- Workplace Injury
Description of the event:
Location of the event:
Property damage paid by 3rd party carrier?
- Yes
- No
If yes, how much?
Is there a police report?
- Yes
- No
If yes, please attach copy
Max. file size: 300 MB.
Has the third party carrier accepted liability?
- Yes
- No
Description of event:
Location of event:
Dangerous condition causing injury:
Facts showing responsible party had prior knowledge of dangerous condition:
Description of event:
Location of event:
Type of claim:
- Third Party Liability
- Nonsubscriber
Does employer have workers comp?
- Yes
- No
If YES and benefits have been paid, amount paid:

Defendant Information
Defendant Name
Insurance Company
Policy Limits
Has the insurance company made an offer?
- Yes
- No
if yes, amount
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CONTACT US
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