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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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    • Attorney Questionaire
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    • Structured Settlement Payments Worksheet
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      West Bloomfield, MI 48323
      248.948.1800

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