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Settlement Pay℠ Intake Form

Step 1 of 5 - Client Information

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Contact Name*
Contact Email*
Attorney Name:*
Attorney Email:*
Firm Name:*
Firm Address*
Street Address Address Line 2 City State ZIP Code
Phone:
How did you hear about the service?*
Which services are you interested in obtaining?*
- Medical & Technical Experts
- Record Retrieval
- Medical Chronology
- Narrative Summary
- Demand Letter
- Medical Opinion
- Mass Tort Evaluation
- Nursing Home
- Life Care Plan
- Pocket Cost Projections
- Medical Cost Projections
- Economic Report
- Vocational Report
- Court Reporting

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Name of Injured / Decedent:*
Name of Plaintiff (Administrator / Client / Heir):*
Phone*
Email*
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Incident*
Date of Death (if applicable)
Category*
- Catastrophic
- Non-catastrophic
Case Type:*
- Motor Vehicle Accident ( MVA )
- Premises Liability
- Product Defect
- Nursing Home Case
- Medical Malpractice Question
- Work Related Injury
If minor (parents name)
Ethnicity
Preferred language
Employed?*
- No
- Yes
Occupation*
Wrongful Death Case?
- No
- Yes
Date of Death*
Attach Death certificate*
Accepted file types: doc, docx, pdf, jpg, jpeg, png.

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Case information
Report Due Date*
Case Status*
- Pre-litigation
- Litigation
- Demand
Trial date set?
- No
- Yes
Trial Date*
Liability Accepted?*
- No
- Yes
- Investigating
Successful claim against this Defendant in the past?*
- No
- Yes
Estimated Case Value*
Claim Summary
Insurance Coverage information
Liability Carrier*
Policy Number*
Policy Coverage*
Other coverage (such as UIM)?*
- No
- Yes
Policy Number*
Policy Coverage*
General Medical*
Injuries?
Plaintiff Still Treating*
- No
- Yes
Date of last treatment*
Total Medical Bills to Date:*
Check all that apply:
- Medical lien
- General Health Insurance
- Medicare / Medicaid
Future Surgery Recommended?*
- No
- Yes

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MVA- Motor Vehicle Accident
Was an Ambulance needed?*
- No
- Yes
After Injury client went to:*
- ER
- Urgent Care
- Chiro
- Doctor
- Home
- Work
- Nursing home
Was client hospitalized?*
- No
- Yes
Was a Traffic Accident Report Produced?*
- No
- Yes
Attach TAR
Drop files here or
Accepted file types: doc, docx, pdf, jpg, jpeg, png.
Type of MVA:*
- Rear-end
- Side Impact
- Front-end
Number of claimants*
Position*
- Driver
- Front passenger
- Rear seat passenger
Was an air bag deployed?*
- No
- Yes
Towed from scene?*
- No
- Yes
Damage to vehicle?*
- Min
- Mod
- Severe
Do you have a repair estimate for Property Damage?*
- No
- Yes
Amount of repair estimate ( in US dollars )*
Photos of Crash
Drop files here or
Accepted file types: jpg, gif, png, pdf, jpeg.
Premises Liability
Was an Ambulance needed?*
- No
- Yes
After Injury client went to:*
- ER
- Urgent Care
- Chiro
- Doctor
- Home
- Work
- Nursing home
Was client hospitalized?*
- No
- Yes
Please choose type which best describes*
- Slip & Fall type
- Something fell on plaintiff
- Security
- Battery
- Dog Bite (or other animal)
Was a police report filed?*
- No
- Yes
Attach Police Report*
Drop files here or
Accepted file types: doc, docx, pdf, jpg, jpeg, png.
Are there photos or video of incident?*
- No
- Yes
Upload Incident Photos*
Drop files here or
Accepted file types: doc, docx, pdf, jpg, jpeg, png.
If liability is being disputed please explain why you believe liability is solid.
Product Defect
Defective Product?*
Summary of how product was defective*
Has this product had a successful claim against it for the same issue before?*
- No
- Yes
Expert report?*
- No
- Yes
Upload report files
Drop files here or
Accepted file types: pdf, doc, docx.
Is this part of a class action type case?*
- No
- Yes
Nursing Home Case
Case Summary*
Did they visit the decedent within 30 days of demise?
- Yes
- No
Have you filed a claim against this home in the past?*
- No
- Yes
If ‘Yes’ was it successful?*
- No
- Yes
If Expert Reports were produced upload here:
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png.
State cap on nursing home case*
Medical Malpractice
Summary of breach of standard of care and resulting injury:*
Have you retained a standard of care expert?*
- No
- Yes
If Yes, attach Report here: (for underwriting purposes only, draft ok)*
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png.
If No expert report is available, please attach medical records supporting claim.
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png.
State med mal cap?*
Work Related Injury
Was an Ambulance needed?*
- No
- Yes
After Injury client went to:*
- ER
- Urgent Care
- Chiro
- Doctor
- Home
- Work
- Nursing home
Was client hospitalized?*
- No
- Yes
Is there an Incident or Police Report?*
- No
- Yes
Upload Incident or Police Report:*
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png.
Are there photos or video of Incident?*
- No
- Yes
Upload photos:*
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png.
If liability is being disputed please explain why you believe liability is solid.

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Click the 'Submit' button below to send the intake form.
Records needed for Settlement Pay℠ Intake Form
- Narrative reports
- Most recent office notes from treating specialists with recommendations if no narrative available
- Diagnosis of concern
- Additional records will be requested as needed
*Please have all records available for upload prior to proceeding with order form. Upload required in final step.
Name
This field is for validation purposes and should be left unchanged.

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medQuest LTD
345 Seventh Ave. Suite 1401
New York, NY 10001

Email: info@medquestltd.com
Phone: 800 MEDMAL-1

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