Attorney Application

Estimated Settlement$0 - $5,000$5,001 - $10,000$10,001 - $15,000$15,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000$50,001 - $75,000$75,001 - $100,000$100,001 - $150,000$150,001 - $200,000$200,001 - $300,000$300,001 - $400,000$400,001 - $500,000$500,001 - $750,000$750,001 - $1,000,000$1,000,000 +

Estimated Time Until Settlement0 months - 6 months6 months - 1 year1 year - 1.5 years1.5 years - 2 years2 years - 3 years3 years +

Liability Established?
YesNo

By Defendant Insurance Company?
YesNo

By Police Report Or Other Source?
YesNo

Lawsuit Filed?
YesNo

Injury Classification--Please Select--Soft TissueSerious InjuryPermanent Injury

Treatment StageNot StartedOngoingReached Maximum Improvement

Injury Type
Broken BonesFracturesHead InjurySpinal / Vertebrae InjuryDislocation / Separation / Tear

Treatment To Date
ER CareChrioP/TMRI / X-RayNeurologist VisitEpiduralSurgeryArthroscopy / DebridementInstrumentationFusion

Epidurals To-Date012345+

Policy Limits$15,000 / $30,000$25,000 / $50,000$50,000 / $100,000$100,000 / $250,000$250,000 / $500,000$500,000 / $1,000,000Self InsuredCommercialUnknown or Not AvailableNot Insured