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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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