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Attorney Application

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Attorney's Name*:		Firm Name:
Phone #:		Fax #:
Email*:
Address:		City:
Zip:		State:
Client's Name:		Client's Phone #:
Is UM/UIM coverage available?		Yes No
Limits of UM/UIM:		Defendant(s):
Name of Court:		Case #:
Client's Insurance:		Defendant's Ins.:
Policy Limits:		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
Medical Expenses:		Lost Wages:
Damage to Car:		Settlement Range:
Verdict Range:		Plaintiff's Demand:
Defendant's Offer:		Lost Wages:
Has the Case Been Set for Arbitration?		Yes No
Settlement Conference Set?		Yes No
Estimated Trial Date:		Est. 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):