ONLINE ATTORNEY QUESTIONNAIRE
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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.
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Privileged & Confidential
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1. |
Plaintiff's Name:
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| 2. |
Date of Incident/ Accident: |
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3. |
Defendant(s): |
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| 4. |
Insurance Company: |
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5. |
Defendant's Policy Limits:$ |
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6. |
Defendant's Policy / Claim #: |
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7. |
Plaintiff's UIM Policy Limits:$ |
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| 8. |
UIM Policy / Claim #: |
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9. |
Suit Filed?: |
Yes
No
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10. |
If Yes, Index #: |
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11. |
Date Filed: |
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12. |
Have any Demands been Made?: |
Yes
No
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13. |
If Yes, Amount of Demand:$ |
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14. |
Have any Settlement Offers been Made?: |
Yes
No
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15. |
If Yes, Verbal or Written?: |
Verbal
Written
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16. |
If Yes, Amount of Offer?:$ |
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17. |
Is Case on a Contingency Basis?: |
Yes
No
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18. |
If Yes, %: |
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19. |
Liability Established or Admitted?: |
Yes
No
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20. |
Will Settlement be
Deposited into Firm's Acct?: |
Yes
No
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21. |
Has Client Received Any of the Following: |
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A. |
ER Treatment?: |
Yes
No
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B. |
MRI?: |
Yes
No
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C. |
CT Scan?: |
Yes
No
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D. |
Fractures?: |
Yes
No
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E. |
Surgery?: |
Yes
No
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22. |
Any Related Pre-existing Conditions or
Injuries?: |
Yes
No
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23. |
If Yes, Explain: |
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24. |
Medical Expenses to Date:$ |
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25. |
Loss Wages to Date:$ |
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26. |
Medical Bills Paid by PIP or Other MedPay?: |
Yes
No
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27. |
If Yes, Coverage Limits?: |
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28. |
What is Your Estimated Value of This
Case?:$ |
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29. |
Estimated Date of Settlement?: |
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30. |
List All Liens to Date (including any prior fundings). If None, So
State: |
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Date: |
Lien: |
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Amount: |
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$ |
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$ |
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$ |
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$ |
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$ |
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This form completed by: |
Contact Phone: |
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