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. At the end you will be asked to submit payment for this demand request. Should you encounter issues in filling out this form or payment please email out tech support at Info@prelitexpert.com.
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Requestors Information
Law Firm Name
*
Request #
*
Example: Demand #2 John Doe DOL 1/1/23
Submitters Name
*
First Name
Last Name
Your Email:
*
example@example.com
Tell us who will be reviewing the drafts of the demand and who we should send it to. Please include the name and email of all the individuals.
Please provide their email addresses.
What Demand Template Would You Like us to use?
My Firm Template
Prelit Expert Sample Template
Combination Template
Upload: Your Firms Template/Sample Demand
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CASE INFORMATION
Name of Your Clients Name
*
First Name
Last Name
Other Plaintiff's Involved: First & Last Name
Date of Loss
*
-
Month
-
Day
Year
Date
Type of incident/demand we should write:
*
Please Select
First Party: Uninsured Motorist Claim
First Party: Underinsured Motorist 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
Ins. Company Addy
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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File Link: If you are sharing link from case management software please enter shareable link here.
Injuries & Medical Information
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.
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Comments/Notes: Is there anything else we should know that is important in us drafting this demand?
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 White PRELIT EXPERT 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. PRELIT EXPERT 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 PRELIT EXPERT and 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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