Date: Client:
Attorney: D/A:
Employer :
Years with Company: Rate of Pay: Hours Per Week:
Workers' Compensation Rate    Is Client receiving WC? Yes No    How Much?
Filed in Court: Yes No T/D Assigned : T/D Expected:
Offer? (amount): Demand? (amount):
Maximum Case Value (Opinion):

How is case value determined in your State:

Settlement Value (Opinion):

How is settlement value determined in your State:
Settlement Prospects: Good Fair Poor
Settlement Expected:  Within 30 days 30-90 days 90-120 day s Other

Strengths/Weaknesses of Case:

Injuries:

Prior injuries:
Defense Attorney's Name: Case/Claim #:
Address:
Phone #: Fax #:
Insurance Co:
Attorney Fee: Litigation Costs (Amt):
Medical Liens (Amt): Other Liens (Amt):
Previous Lawsuit Funding Company::
Amount:: Payback:

Additional Comments - Please use this area to provide additional information with special attention to nuances of  State Workers’ Comp law. 
 

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