Plaintiff Application Introduce YourselfI am... A PlaintiffAn Attorney or Legal ProfessionalPlaintiff InfoState of Residence *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLaw Office Contact InfoCase InfoCase Type *Auto AccidentPremises Liability / Slip & FallFELAJones ActOtherSurgery YesNoScheduled or LikelyDate of Incident [group attorney-fields]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? YesNoBy Defendant Insurance Company? YesNoBy Police Report Or Other Source? YesNoLawsuit Filed? YesNoInjury Classification--Please Select--Soft TissueSerious InjuryPermanent InjuryTreatment StageNot StartedOngoingReached Maximum ImprovementInjury Type Broken BonesFracturesHead InjurySpinal / Vertebrae InjuryDislocation / Separation / TearTreatment To Date ER CareChrioP/TMRI / X-RayNeurologist VisitEpiduralSurgeryArthroscopy / DebridementInstrumentationFusionEpidurals 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[/group]
