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Settlement Pay℠ Intake Form
Step 1 of 5 - Client Information
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Contact Name
*
Contact Email
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Attorney Name:
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Attorney Email:
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Firm Name:
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Firm Address
*
Street Address
Address Line 2
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Name of Injured / Decedent:
*
Name of Plaintiff (Administrator / Client / Heir):
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Phone
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Email
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Date of Birth
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Address
*
Street Address
Address Line 2
City
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
State
ZIP Code
Date of Incident
*
Month
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Date of Death (if applicable)
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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
*
Month
1
2
3
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12
Day
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Attach Death certificate
*
Accepted file types: doc, docx, pdf, jpg, jpeg, png.
Case information
Report Due Date
*
Month
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Case Status
*
Pre-litigation
Litigation
Demand
Trial date set?
No
Yes
Trial Date
*
Month
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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
*
Month
1
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Day
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1982
1981
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1921
1920
Total Medical Bills to Date:
*
Check all that apply:
Medical lien
General Health Insurance
Medicare / Medicaid
Future Surgery Recommended?
*
No
Yes
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.
Click the 'Submit' button below to send the intake form.
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