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Name

Phone Number

Email

Additional information about your case


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Name

Phone Number

Email

Additional information about your case


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Name


Phone Number


Email Address


Address of Loss

Property Owner(s):

Insurance Carrier

Policy Number


Policy Holder(s)

Please describe the type of damages you observed to your home/property and when the damages were first observed

Name

Phone Number

Address (Street Address)

City

State

Zip

Email Address

Builder

Year Built

Referred by?

Additional Information about your situation:

Name

Phone Number

Address (Street Address)

City

State

Zip

Email Address

Date of Birth

Sex
FemaleMaleOther

Ethnicity
White/CaucasianBlack/African AmericanAsianEast IndianHispanic/LatinoMiddle EasternNative AmericanPacific IslanderMulti-EthnicOther

Who is/was your employer?

What is/was your job title/position and what were your job duties?

What is/was your salary?

How many employees work/worked at your location? At your employer as a whole?

What were your dates of employment?

Who hired you and what was their job title/position?

Did your employer provide you with performance evaluations/feedback? If so, please describe them.

Have you ever received any write ups or other disciplinary action by your employer? If so, please describe them, including the date(s) you received each write up or disciplinary action.

Are you still employed, have you resigned, or have you been terminated?
—Please choose an option—EmployedResignedTerminated

If you were terminated or forced to resign, who terminated you and what was their position, age, sex, and ethnicity?

What was the reason given for your termination?

Has your position been filled? If so, what is the age, sex and ethnicity of your replacement?

Please describe in detail the issues you have/had with your employer, including all relevant dates and names:

If you’ve been terminated, have you found new employment? If so, please list the name of your new employer, your job title, the date you were hired, and your current income.

Please list any individuals that may be able to provide information relevant to your claim, including whether they are a current or former employee, and what information they have:

Referred by?

Please leave this field empty.

Name

Phone Number

Address

City

State

Zip

Email Address

Date of Birth

Marital Status
SingleMarriedPartneredDivorcedWidowed

Children
YesNo

Any Children Under the Age of 25?
YesNon/a

Please provide a chronological description of the events leading to and including your claims of medical malpractice and describing the injuries you received because of this malpractice. Please include all pertinent dates, the names of involved physicians, all pertinent symptoms and diagnosis, and the treatment initiated for each condition.

When do you believe the negligence occurred?

Who do you believe was negligent?

How was the healthcare provider negligent?

What are your injuries?

Are they continuing injuries?
YesNo

Prognosis for recovery?

Did any subsequent healthcare providers criticize the care provided by the negligent healthcare provider?
YesNo

If yes to the above, what did they say?

Do they have a copy of the medical records?
YesNo