DEMAND REQUEST FORM
Please fill out the following demand prep sheet to the best of your abilities so the demand writers can process the demands more efficiently. It is our goal to provide you a quality demand and this information is necessary in doing so. Should you encounter issues in filling out this form please email our tech support at demands@staffilocity.com.
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Requestors Information
Name of Your Firm
*
Your Name:
*
First Name
Last Name
Email:
*
example@example.com
Other than you, who else should we send the demands to?
Please provide their email addresses.
Request #
*
Example: Demand #2 John Doe DOL 1/1/23
What Demand Template Would You Like us to use?
Your Firm Template
Our Sample Template
Combination Template
Letter Head: Please Upload your firm's letterhead.
*
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Firm Demand Template: If you would like us to use your firms demand template please upload here.
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Sample Demand: Please provide sample if you chose to use your firm's template.
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CASE INFORMATION
Clients Name
*
First Name
Last Name
Client's DOB:
*
-
Month
-
Day
Year
Date
Type of incident/demand we should write:
*
Please Select
First Party UM/UIM Claim
Third Party Claim Against Defendant
Premise Liability
Dog Bite
Other
If 'OTHER' please indicate type of case.
Example: Habitability, Breach of contract etc.
Liability Status
*
Please Select
UM/UIM Coverage Afforded
Accepted
Denied
Comp Negligence
Pending/Unknown
Liability: If liability is argued tell us what they are disputing so we can add more details in arguing liability.
Ex. Lane change dispute
Facts Of Loss/Description:
*
What and how did the incident occur?
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Claim Information
Please indicate who we are sending the demand to.
Who's Insurance are we sending demand to.
First Party UM/UIM
Third Party
Name of Insurance Company
*
Claim Number
*
Adjuster Information
First Name
Last Name
Adjuster Email
example@example.com
Adjuster Fax Number
Please enter a valid phone number.
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Evidence & Property Damage
Evidences: Please pick the following that apply and ensure to upload documetns if applicable.
*
Police Report/Incident Report
Video Footage
Photos
N/A
UPLOAD: Applicable Evidence Documents.
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You can upload more than one document here. Drag and drop from desktop or folder.
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Property Damage: Has property damage been taken care of ?
Yes was total loss or no do not include
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Injuries & Medical Information
Will you be claiming injuries in this demand?
*
Please Select
Yes
No
Medical Records: Please upload all supporting medical records
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Medical Billing: Please upload all supporting medical billing, liens, collection notices etc.
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You can upload the exhibit package you will be sending if you do not want to upload billing and records separately.
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Loss of Earnings/Wages
Will you be claiming loss of earnings/wages?
Yes
NO
Yes: Will enter at later date
What is the time period you ware claiming loss wages for?
Example: 2 Days or 4 months etc
Loss Wages: Upload your supporting documents
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Ex. W2 statements, paystubs, doctors notes etc.
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Other Damages
Future Medicals: If you have a specific amount you would like us to put for futures please advise. If you have a specific way of calculating please advise. If not, put N/A.
Loss of Enjoyment of Life: (Pain & Suffering) How did the injuries affect their HOME, WORK, SOCIAL, RECREATIONAL LIVES, along with SLEEP, MARRIAGE & RELATIONSHIPS?
Demand Amount:
If you have a specific amount please specify otherwise we will assume it is policy limits.
Comments/Notes: Is there anything else we should know that is important in us drafting this demand?
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Attorney Acknowledgment & Consent
FINAL CONFIRMATION: By submitting this form I hereby certify that the information provided herein is accurate and complete to the best of my knowledge and belief. I acknowledge that this form has been completed based on the information available to me at the time of submission. I understand and agree that Staffilocity is not responsible for the verification of the information provided nor for any outcomes resulting from the use of this information in demand letters or any other legal processes. Staffilocity acts solely as a facilitator in the preparation of demand letters based on the information I have provided.I hereby release, indemnify, and hold harmless Staffilocityand its agents, employees, and representatives from any claims, damages, losses, liabilities, costs, and expenses, including reasonable attorney’s fees, arising from or related to any inaccuracies or omissions in the information provided.This acknowledgment and consent form is an agreement that I have read and understood the terms set forth above, and I agree to be bound by them.
Acknowledge & Consent
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