ONLINE ATTORNEY QUESTIONNAIRE

To ensure proper evaluation of your client’s case, we ask that your firm answer the following questions. Note: This information is for case evaluation purposes only, and will not be shared with your client.

ONLINE ATTORNEY QUESTIONNAIRE


Plaintiff’s Name:

Date of Incident/ Accident:

Defendant(s):

Insurance Company:

Defendant’s Policy Limits:$

Defendant’s Policy / Claim #:

Plaintiff’s UIM Policy Limits:$

UIM Policy / Claim #:

Suit Filed?:
Yes   No
If Yes, Index #:

Date Filed:

Have any Demands been Made?:
Yes   No
If Yes, Amount of Demand:$

Have any Settlement Offers been Made?:
Yes   No
If Yes, Verbal or Written?:
Verbal   Written
If Yes, Amount of Offer?:$

Is Case on a Contingency Basis?:
Yes   No
If Yes, %:

Liability Established or Admitted?:
Yes   No
Will Settlement be Deposited into Firm’s Acct?:
Yes   No
Has Client Received Any of the Following:
ER Treatment?:
Yes   No
MRI?:
Yes   No
CT Scan?:
Yes   No
Fractures?:
Yes   No
Surgery?:
Yes   No
Any Related Pre-existing Conditions or Injuries?:
Yes   No
If Yes, Explain:

Medical Expenses to Date:$

Loss Wages to Date:$

Medical Bills Paid by PIP or Other MedPay?:
Yes   No
If Yes, Coverage Limits?:

What is Your Estimated Value of This Case?:$

Estimated Date of Settlement?:

List All Liens to Date (including any prior fundings). If None, So State:

Date: Lien: Amount:

This form completed by:

Contact Phone:










Apply for Lawsuit Funding

To apply for lawsuit funding, please complete the form below, and we will process your request immediately.

Applicant Name *

Phone #1 *
- -
Email address *

Date of Birth (mm/dd/yyyy) *

Postal Address *

City *

State *
Type of Case *

Have you Received Previous Advance? *
Yes     No
if Yes how Much?

Attorney Name *

Attorney Phone Number *
- -
Attorney Fax
- -
Attorney Email

How much money do you need? *
Describe the Incident? *
Describe the Injuries Sustained? *


I have read and agree to the terms of the Authorization to Release Information