REFER A CASE

Case Data

     
Date:  
     
Your File #:  
     
Loss Date:  
     
Claim #:  
     

Claim Information

     
Facts of Accident:  
     
Injuries Sustained:  
     

Case Status

     
Suit Filed:  
Yes
No
   
Mediation Date:  
     
Trial Date:  
     
Jurisdiction:  
     
Demands:  
     
Offers:  
     

Claimant/Victim Information

     
#1    
     
Name:  
     
D.O.B.:  
     
Sex:  
Male
Female
   
State:  
     
Phone:  
     
Social Security #:  
     
Dependents names:  
     
     
#2    
     
Name:  
     
D.O.B.:  
     
Sex:  
Male
Female
   
State:  
     
Phone:  
     
Social Security #:  
     
Dependents names:  
     

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         Click + to submit more.
     
     
#3    
     
Name:  
     
D.O.B.:  
     
Sex:  
Male
Female
   
State:  
     
Phone:  
     
Social Security #:  
     
Dependents names:  
     
     
#4    
     
Name:  
     
D.O.B.:  
     
Sex:  
Male
Female
   
State:  
     
Phone:  
     
Social Security #:  
     
Dependents names:  
     
     
#5    
     
Name:  
     
D.O.B.:  
     
Sex:  
Male
Female
   
State:  
     
Phone:  
     
Social Security #:  
     
Dependents names:  
     
     

Services Requested of
     
Proposals:  
Yes
No
   
Needs/Type of plan (i.e. life, lumps, etc.):  
     
Premium:  
     
Qualified
Settlement Fund: 		 
Yes
No
   
Special Needs Trust:  
Yes
No
   
Pre-Meeting with plantiff & attorney:
 
Yes
No
   
Mediation Attendance:  
Live
Phone
   
     

Settlement/Verdict Details
     
Total Settlement/Verdict (or anticipated):  
     
Fees & Cases  
     
Liens:  
     
Cash Up Front:  
     
Structured Settlement Offices (if yes, please forward to us):  
Yes
No
   
     

Plantiff Attorney

     
Name:  
     
Firm:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
Email:  
     

Defendant/Insurance Carrier

     
1#    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
     
#2    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     

[−]   More Defendant/Insurance Carriers?  
         Click + to submit more.
     
     
#3    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
     
#4    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
     
     
#5    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
     
#6    
     
Insured:  
     
Liability Carrier(s) Self Insured(s):  
     
Coverage Amount(s):  
     
Contact:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
     

Defense Attorney
     
Name:  
     
Firm:  
     
Phone #:  
     
Fax #:  
     
Address:  
     
Email:  
     

Other notes, client requests, misc.:

     
     
   



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