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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
MM
DD
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
Medical Treatment and Bills to Date:
Are there any imaging reports or records?
Yes
No
if yes, please attach
Drop files here or
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
MM
DD
YYYY
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
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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