CASE Records Upload Portal

CASE Records Upload Portal
Company Name
Attorney Name:

First NameLast Name
Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Insurance Company:
Insurance Company Address (optional):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claims Adjuster Name:
Claimant:
Claim #:
Date Of Loss:
Our Demand of: $
Your Settlement Amount Was: $
Please include the complete claim records including all medicals, associated expenses, report from client, report form others, report from insurers, accident report, police officer statements, and any citations.

If The Following Information Is Not Already Included In The Claim Data You Upload, Please Fill In the Data Below.
Property Damage
Physical Vehicle Damage
Vehicle Repair Cost:
Loss of Vehicle/Car Rental Costs:
Vehicle's Diminution In Value:
Deductible Paid To 1st Party Insurer:
Additional Property Losses/Costs:
Total Property Damage/Vehicle Losses/Repair/Rental/Diminution/Additional:
Medical Expenses
Current Treatment Expenses:
Current Lab/Diagnostics Expenses:
Emergency Room Expenses:
EMS Expenses:
Hospital Expenses:
Ambulance Expenses:
Medivac Expenses:
General Practitioner Expenses:
Osteopath Expenses:
Chiropractor Expenses:
Pain Management Expenses:
Orthopedic Expenses:
Physical Therapy Expenses:
Neurologic Expenses:
Surgical Expenses:
Radiology Expenses:
Medication Expenses:
Durable Medical Equipment Expenses:
Other Current Medical Costs:
Total Current Medical Expenses:
Income Loss
Current Income Losses:
Future Income Losses:
Total Past and Future Income Losses:
Mileage Costs
Total Mileage Loss:
(if you want them included)
Future Medical Expenses

If there are any future medical procedures that have been prescribed and there is an accompanying letter, prescription, invoice, or 2nd opinion from a medical professional, please upload or list here with associated costs:
Future Injections
Future Surgeries
Future Diagnostics
Future Labs
Future MRI's
Future DME's
Total Future Medical Expenses:
Case Costs and Expenses
Administrative Costs
Filing Fees
Mediation
Medical Records
Police Reports
Phone
Postage
Copying
Messenger
Delivery
Investigators
Doctors Narrative Report
Independent Medical Validation of Medical Records
Special Radiology Consulting (AOMSI) Fees
Location of Expert Witnesses
Expert Witness Fees
Depositions
Transcripts
Jury Fees
Court Reporting
Travel
Trial Exhibits
Total Case Costs and Expenses
Total Of All Economic Losses
Total Property Damage:
Total Past and Future Medical Expenses:
Total Past and Future Income Loss:
Total Past and Future Mileage Costs:
Total Case Costs and Expenses:
Administrative Costs:
Total of Past and Future; Property, Medical, Income, Mileage, Economic, Case & Admin Costs:

Order Audit

$1,500.00

Quantity

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

CASE Records Upload Portal

Property Damage

Medical Expenses

Income Loss

Mileage Costs

Future Medical Expenses

Case Costs and Expenses

Total Of All Economic Losses