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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:
    Prior Injuries:
    Defense Attorney: Case #:
    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.


    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.

    Litigation Funding