Full Application

Attorney Application

Plaintiff Name: (First and Last Name)*
Amount $ Requested (If Known)*
DOB*
Date Format: MM slash DD slash YYYY
Social Security #
Home State
Phone*
In Bankruptcy?
Number of Claims Filed
Prior Cash Advance?
If Yes, from what company?
Child Support Lien?
Tax Lien?
Case Information
Case Type
Date of Accident
Date Format: MM slash DD slash YYYY
Liability Established?
Complaint Filed?
Defendant's Name:
Claim Number
Insurance Company
Insurance Limits ($)
Police Report? (If Yes, Please Attach) Please attach PR below or fax to 954.246.4805
Attach Police Report:
Accepted file types: pdf, png, gif, jpg, jpeg.
Description of Accident: (If no police report)
Injuries Sustained
Does Plaintiff have PIP/MP/UIM or equivalent?
If Yes Above, Amount of PIP/MP/UIM?
Medical Treatment
Any Pre Existing Injuries/Conditions?
MRI?
Auto Damage ($)
Total Medical Bills ($)
Medical Lien ($)
Attorney Input
Name of Person Filling Out This Application: (If not Attorney)
Email
If you are a paralegal and would like to send this partially completed application to the Attorney for their additional input or signature, simply click "Save For Later" at the bottom of this page. A link will be generated and sent to the email address you provided above, and you can forward that link to the attorney to complete at their convenience.
Any relevant thoughts/feelings about your client's case?
Opinion of Chance Plaintiff will Win Case (Non Binding Estimate):
Estimated Time of Settlement (Non Binding):
Has the Demand Gone Out?
If Yes, Amount Demanded ($)?
Settlement Amount Offered ($):
Approximate Case Settlement Value:
Low Settlement ($):
High Settlement ($)
Name of Law Firm:
City/State:
Plaintiff's Attorney:
Digital Signature of Attorney or Paralegal in charge of case: By signing here I acknowledge that the information I have submitted is true to the best of my knowledge.
Clicking "Save For Later" will generate a weblink back to this application in its current (partially or fully completed) form. The link will be emailed to you at the address you supplied above, and you (or someone else) can click on it to return to this application and complete it at any time.
Name
This field is for validation purposes and should be left unchanged.

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Full Application