The following information is not required but it helps us process your application as quickly as possible. Click on each of the sections below to provide the requested information. When finished, please scroll down and click the green submit button to finalize your application.
Describe the treatments you have received and are receiving for your injuries:
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What is the status of the case (e.g. not filed, filed, settled, settlement offer made)?
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If you were working at the time of the incident, accident or injury, how much time did you miss from work because of the incident, accident, or injury?
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Are there any outstanding liens against you and/or the case? (medical, hospital, workman's comp, disability, IRS, etc.)
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