Attorney Questionnaire


Please fill out the information so we may provide your client with funding.

Client’s Information

First Name

  
MI

  
Last Name

Attorney’s Information

First Name
 
MI
 
Last Name

Attorney’s Firm Name

Street Address

City
  State
  Zip Code

Attorney’s Phone Number

Attorney’s Fax Number

Defendant’s Information

First Name
 
MI
 
Last Name

Defendant’s Attorney

First Name
  MI
  Last Name

 

Defendant’s Attorney’s Phone

Defendant’s Attorney’s Fax

Case Information

Type of Case

Date of Accident


Suit filed?
Yes
No
Mediation Date

Award


Case Number

County of Court

Plaintiff Accept

Plaintiff Reject

Defendant Accept

Defendant Reject

Offer Amount

Demand Amount

Case Value

Plaintiff Reject

Settlement Prospects  
Good
Fair
Poor

Trial Date

 
Hard
Soft

Liability Strengths

Liability Weaknesses

Injuries

Prior Injuries

Insurance Company

Claim #
Policy Limits

Attorney Fee

Litigation Costs


Medical Liens

Lien Holder

Lien Holder

Lien Holder

Additional Comments

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