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Client Information

First Name

Initial

Last Name

Date of Birth

Telephone

Clients Social Security

Attorney Information

First Name*

Initial

Last Name

Firm Name

Phone Number*

Fax Number

Email Address*

Case Information

Type of Case

Date of Accident

Property Damage $

Suit filed?
YesNo

Arbitration Date

Mediation Date

Trial Date

Award

County of Court

Offer Amount

Demand Amount

Case Value

Settlement Prospects
GoodFairPoor

Injury Information

Injuries

Surgery?
YesNo

Prior Injuries

Total Medical Bills

First and Last Date of Treatment

Defendants Insurance Company

Claim Number

Policy Limits

Attorney Fee

Litigation Costs

Medical Liens

Lien Holder

Additional Comments

Additional Comments