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Pre-Legal Settlement Advance Quotation Form

Your Name
Your Email Address
Contact Phone Contact Fax
Victim's (Plaintiff's) Name
       

Lawsuit / Case Information Worksheet

 
Type of case you have Auto Related
Drug Related
Product Liability
Wrongful Death
Construction Related
Medical Malpractice
Workers Compensation
Other
Victim's Occupation Date of Event
Is the Plaintiff able to work? Yes     No    
Name of Attorney
Attorney's Email
Attorney's Phone    
Name of Law Firm
Describe the nature of your case, the amount of funds requested, and why you are seeking funds.
       
Please answer the math question.   The sum of 9 + 3 =