* Law Firm:

* Attorney Name:

* State Bar #:

* E-mail Address 1:

* Work Phone:

Fax Phone:

Client Name:

Type of case:

Date of Incident :

City and State of Incident:

Has Liability been established or admitted?:

What are the Liability issues?

Describe Client Injuries:

Any Causation Issues?:

Total Damages:

Total Outstanding Liens/Loans:

Your estimated Value of case?:

Has Insurance coverage been confirmed/amount?:

Total Cash Advance requested by Client?:

Any Offers?:

Estimated time to settle/current status:

Why wouldn't this case settle?:

 Previous Law Firm involved?

Other Information::