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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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    • Attorney Advance Form
    • Attorney Questionaire
    • New Funding Intake Form
    • Structured Settlement Payments Worksheet
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    • Downloadable Forms
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      Suite 180-124
      West Bloomfield, MI 48323
      248.948.1800

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