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Consultant's Name*:		Email *:
Phone #:		Cell #:
Attorney's Name:		Firm Name:
Firm Address:		City:
Zip:		State:
Firm's Phone #:		Firm's Fax:
Firm's Email:
Client's Name:		Client's Phone:
Is UM/UIM coverage available?		Yes No
UM/UIM coverage limits:
Defendant(s):
Name of Court where case was filed (if filed):
Case # :		Client's Insurance:
Defendant's Insurance (list all that apply):
Policy Limits for the Defendant's Insurance:
Date of Accident:
Is this a Motor Vehicle Accident?		Yes No
Is this a Worker's Comp Case?		Yes No
Describe Accident:
Describe Injuries Sustained:
Describe Medical Treatment:
MRI?		Yes No
Surgery?		Yes No
Fractures?		Yes No
Taken to the Emergency Room?		Yes No
Length of Hospital Stay?
Still in Treatment?		Yes No
Date of First Doctors Visit:
Medical Expenses:
Lost Wages:
Amount of Damage to Client's Car:
Settlement Range:
Verdict Range:
Plaintiff's Most Recent Demand:
Defendant's Offer:
Has the Case Been Set for Arbitration?		Yes No
Settlement Conference Set?		Yes No
Estimated Trial Date:
Estimated Closure Date:
What are the Impediments to Early Settlement?
Do You Have the Following?
Police/Incident Report:		Yes No
Demand Letter:		Yes No
Settlement Offer by the Defendant:		Yes No
Medical Report:		Yes No
Prior Advances?		Yes No
(if yes, list issuer, date, amount and fees/interest rate)
Additional assignments of, and liens upon, the proceeds of the case (e.g., medical liens, other third-party liens, child support, Medicaid, etc) (Attach if necessary)
Prior/Subsequent Injuries and/or accidents?		Yes No
(if yes, state the date and describe the injuries):
Client Ever Convicted of Felony?		Yes No
(if yes, explain)
Client Ever Declared Bankruptcy?		Yes No
(if yes, state date and current status):
How did you learn about LawMax?: