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Case Intake Form

Please fill out the form below.

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Select Your Lien Type(s)*
Would you like to add another lien?*
- Yes
- No
Select Your Lien Type(s)
Would you like to add another lien?*
- Yes
- No
Select Your Lien Type(s)
Would you like to add another lien?*
- Yes
- No
Select Your Lien Type(s)

Claimant Information
Name*
First Last
Social Security Number*
Gender*
- Male
- Female
DOD
If deceased please provide executor information
Address*
Street Address Address Line 2 City State ZIP Code
Email
If Dependent, please identify guardian or personal representative
Name
First Last
Relationship
Phone
Email

Insurance Information
Include a copy of the insurance card if applicable.
Medicare HIC #
Medicare Advantage #
Medicaid ID Number
State
Military Sponsor Number
Branch
Rank
Insurance Company
Policy #
Recovery Contractor
Currently Employed?
- Yes
- No
Employer Name

Case Information
Include additional documentation regarding incedent
Date of Incident*
Injuries*
Description of Incident*
Has case settled?*
- Yes
- No
Date of Settlement
Settlement Amount
Attorney's Fees
Case Costs
Pre-existing Conditions*
Liability Insurer/Defense Attorney/Defendant
Policy Number
Phone*
Contact*

Plaintiff Attorney Information
Attorney Name*
First Last
Attorney Email*
Firm*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Paralegal/Legal Assistant
Paralegal/Legal Assistant Email

Lien Resolution Intake

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