Attorney Application

Please fill in all applicable fields
All fields with an asterisk are required

Attorney Information
Name of Firm *
Name of Attorney * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Fax * - (###) - ### ####
Case Liens to Date
If any, please include details
Case Description
City incident occurred in *
State incident occurred in *
Date of incident * / MM / DD YYYY
Type of case *
If other, please describe
What occurred *
Describe injuries *
Medical bills to date * $ . Dollars Cents
Insurance carrier *
Coverage amount * $ . Dollars Cents
Name of defendant (Who you are suing) * First Last
If auto accident, property damage amount $ . Dollars Cents
Property claim paid? (for automobile cases ONLY) Yes No
If yes, name of insurance company
Does your client have personal injury protection? (for automobile cases ONLY) Yes No
If yes, how much is the personal injury protection for? $ . Dollars Cents
Has a lawsuit been filed? * Yes No
Date of filing / MM / DD YYYY
Case value (your opinion) * $ . Dollars Cents
Attorney Questionnaire (Fill out below ONLY if Attorney is applying for Plaintiff)
Name of Client First Last
Mediation date / MM / DD YYYY
In suit? Yes No
Award amount $ . Dollars Cents
Case number
County of court
Plaintiff Accepted offer Rejected offer
Defendant Accepted offer Rejected offer
Amount offered $ . Dollars Cents
Demand amount $ . Dollars Cents
Settlement prospects
Trial date / MM / DD YYYY
Liability (strengths and weaknesses)
Explain briefly
Injuries
Explain briefly
Prior injuries
Explain briefly
Insurance claim number
Policy limits
Attorney fee $ . Dollars Cents
Litigation costs $ . Dollars Cents
Additional comments
Type the letters you see in the image below.

Attorney Application

Attorney Application

Attorney Information

Case Liens to Date

Case Description

Attorney Questionnaire (Fill out below ONLY if Attorney is applying for Plaintiff)