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Attorney Intake Form
Step
1
of
2
50%
FOR ATTORNEY ONLY
NOC NEEDED:
Yes
No
NO-FAULT APPLICATION FILED:
Yes
No
LAW SUIT FILED:
Yes
No
NEED TO BE FILED ASAP:
Yes
No
PHOTO(s):
Yes
No
EVALUATION OF LIABILITY:
EVALUATION OF DAMAGES:
FRACTURE(s):
Yes
No
SURGERY(S):
Yes
No
HOSPITAL ADMISSION:
Yes
No
If yes, period of admission: From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Notes
FOR PREMISES CASES ONLY (owner and/or managing company information):
Name
Address
Phone Number
Name
Address
Phone Number
NAME OF THE ATTORNEY CASE IS GOING TO BE ASSIGNED TO:
NAME OF THE PARALEGAL CASE IS GOING TO BE ASSIGNED TO:
REFERRAL SOURCE: PKA
Yes
No
IF NOT, REFERRED BY:
{all_fields}
