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Online Attorney Questionnaire






    Date: Client:
    Attorney:
    D/A: Type of Case:
    In Suit? YesNo
    Mediation Date: Award:
    Plaintiff: AcceptReject Defendant: AcceptReject
    Demand Amount: Offer Amount:
    Case Value (opinion):
    Settlement Prospects: GoodFairPoor
    Settlement Expected: Within 30 days30-90 days90-120 daysOther
    Trial Date:
    Liability (Strengths/Weaknesses):
    Injuries:
    Prior Injuries:
    Insurance Co: Claim #:
    Adjuster's Name: Policy Limit:
    Address:
    Phone: Fax:
    Defense Attorney: Case #:
    Address:
    Phone: Fax:
    Attorney Fee: Litigation Cost:
    Medical Liens: Other Liens:
    Previous Lawsuit Funding Company:
    Amount: Payback:
    Additional Comments:

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