I am a
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New Referring Attorney
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Plaintiff
Request Amount is
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Type of Case
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Vehicle Accident
Truck Accident
Slip & Fall
Premise Liability
Settled Cases
Dog Bite
Others
Date of Accident
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Month
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Day
Year
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Name
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Law Firm Name
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Phone Number
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Lawyer's Email
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Case Handler Name
Case Handler's Email
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Are you the Original Attorney?
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No
If No, who was the original Attorney?
Full Name
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Plaintiff's Email
Address
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Phone Number
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Date of Birth
Social Security Number
Plaintiff is the
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Driver
Passenger
Is Plaintiff Prop 213?
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Was Defendant DUI?
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No. of Passengers in Vehicle
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Status of Liability
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Accepted
Denied
Case Number
Venue
Status of the Case
Negotiating Settlement
Preparing Demand
Litigation
Settled
Statutory Liens (check all that applies)
Workers Comp
MediCare
MediCal
Child Support
Describe details of Accident
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Last Settlement Offer
Your Estimated Value of the Case
Description of Property Damage
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Total Loss
Repairable
Has Property Damage Been Paid?
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Does Plaintiff have Prior Advances?
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Yes
No
If Yes, how much?
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Name of Funding Company
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Describe Injuries
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Surgery Required?
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Type of Surgery
Medical Bills to date?
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Estimated Future Medical Bills
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Amount Paid for Property Damage
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Property Damage Paid By
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Plaintiff Insurance
Defendant Insurance
Defendants Car / Insurance Information
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Defendants Policy Coverage
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Claim Number
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Policy Number
Client's UM / UIM Coverage
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UM / UIM $ Amount?
Police Report / incident Report
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Surgery Report
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Defendant's Settlement Offer
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Signed Settlement Release
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Images of Accident / Property Damage
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Summary of Medical Expenses to Date
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