Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Who is the insured and TPA? (if applicable)
Who is the handling adjuster?
Please provide us with your claim number:
Has an ADJ been assigned?
Yes
No
What is the ADJ?
Is there a decision date pending?
Yes
No
Is this case delayed or denied?
Yes
No
If yes, what is the date of the delay or denial?
What is the Decision Date?
Is there a hearing or appearance already scheduled? (MSC, Trail, Deposition, etc.) question
Yes
No
What is the appearance type and date?
Who is your preferred attorney for handling? (optional)
How complete is the file referral?
The file referral is complete
Additional documents will be sent at a later time
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