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Online Worker’s Compensation Attorney Questionnaire





Date: Client:
Attorney: D/A:
Employer: Years with company
Rate of Pay: Hours Per Week:
Workers Compensation Rate:
Is Client Receiving WC YesNo How Much:
Filed in Court YesNo
T/D Assigned: T/D Expected:
Demand Amount: Offer Amount:
Maximum Case Value (opinion):
How is case value determined in your State:
Settlement Value (opinion):
How is settlement value determined in your State:
Settlement Prospects: GoodFairPoor
Settlement Expected: Within 30 days30-90 days90-120 daysOther
Strengths/Weaknesses of Case:
Injuries:
Prior Injuries:
Defense Attorney: Case #:
Address:
Phone: Fax:
Insurance Co:
Attorney Fee: Litigation Cost(s):
Medical Liens: Other Liens:
Previous Lawsuit Funding Company:
Amount: Payback:
Additional Comments - Please use this area to provide additional information with special attention to nuances of State Workers’ Comp law.

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One of our Financial Representatives will be in contact with you once you have submitted this form. If you have any questions, please contact Litigation Funding Corp at 1-866-548-3863.

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