Settlement Submission

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Attorney NameType your name
First Name
Last Name
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FirmPlease provide your firms name
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EmailPlease provide us with your email address
example@example.com
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Phone NumberWhat is the best number to contact you?
Area Code
Phone Number
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Client's NameEnter Client's First and Last Name
First Name
Last Name
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Date of LossEnter the date the injury occurred
Date
Month
Day
Year
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Date of SettlementEnter the date the case was settled
Date
Month
Day
Year
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EmailEnter client's email address
example@example.com
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Phone NumberEnter client's cell phone number
Area Code
Phone Number
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Did you obtain medpay?
YESNO
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If you answered yes, please enter the amount obtainedEnter amount of medpay collected
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Enter retainer %Was this obtained pre-lit/Post filing/Post Arbitration
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Did you obtain a 3rd party settlement?
YESNO
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If you answered yes, please enter the amount obtainedEnter amount of 3rd party settlement
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Enter retainer %Was this obtained pre-lit/Post filing/Post Arbitration
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Did you obtain a 1st party settlement?
YESNO
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If you answered yes, please enter the amount obtainedEnter amount of 1st party settlement
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Enter retainer %Was this obtained pre-lit/Post filing/Post Arbitration
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Upload fully executed retainer
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Max. file size: 10.6MB
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Who is the referring attorney?Select referring attorney
Bergener Mirejovsky, APC
Law Offices of Eleanor Miller
Law Offices of John Oh
Rafii Nazarian
Dayan Houman
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Fee Split AgreementAs per 2-200
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Upload Addendum
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Max. file size: 10.6MB
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Advanced Case CostsEnter your costs
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Co-Counsel Advanced Case CostsPlease email co-counsel to see if they have any costs
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Outstanding Deposition ChargesDeposition & Court Reporter Charges
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Wexco International (Expert)Site Inspection for premises liability matters
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Upload itemization of costs
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Max. file size: 10.6MB
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Dont feel like entering the medicals, just upload them! We'll do the work for you.
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Max. file size: 10.6MB
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Add Medicals One By One
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Does your client have a child support lien?
YESNO
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Enter child support contact
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Enter child support agent phone number
Area Code
Phone Number
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Please tell us what the client is expecting to recoverVery important that we keep our promises to the client
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SignatureBy submitting this form, you understand that LRS is not responsible for bills that are omitted. LRS is not responsible for the payment of any liens on referred matters. LRS will not be responsible or named in legal issues that may arise.
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