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Pre-Legal Settlement Advance Quotation Form
Your Name
Your Email Address
Contact Phone
Contact Fax
Victim's (Plaintiff's) Name
Lawsuit / Case Information Worksheet
Type of case you have
Auto Related
Drug Related
Product Liability
Wrongful Death
Construction Related
Medical Malpractice
Workers Compensation
Other
Victim's Occupation
Date of Event
Is the Plaintiff able to work?
Yes
No
Name of Attorney
Attorney's Email
Attorney's Phone
Name of Law Firm
Describe the nature of your case, the amount of funds requested, and why you are seeking funds.
Please answer the math question
. The sum of 9 + 3 =