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*What you need: personal information about your client and all pertinent case documents.

MVA Application

Premises Application

Firm contact

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Email

Attorney name

Phone number

Whom we should contact

Contact name

Contact email

Contact phone

Law firm

Firm address

How did you hear about us?

Internet

Email

Colleague

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Used Before

Other

Other option

Tell us about your client

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Client name

DOB

DOI

Death case?

Yes

No

Date

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Tell us about your client

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Client name James

DOB 03.15.1984

DOL 01.05.2010

Name of injured/decedent

Name of Plaintiff (administrator/client/heir)

Client Email

Client Phone Number

Client Address

Client language

English

Spanish

Portugese

Other

Tell us about your client

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Client name James

DOB 03.15.1984

DOL 01.05.2010

Tell us about your client & case

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Client name James

DOB 03.15.1984

DOL 01.05.2010

Case status

Demand

Pre-litigation

Litigation

Attach complaint

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Trial Date

No Trial Date

Has the adverse party accepted liability?

The facts make liability clear

No

Clear

Investigating

Provide the at fault party's insurance carrier’s information:

Carrier name

Policy limits

Policy number

Plaintiff still treating

Yes

No

Date

Future Surgery Recommended?

Yes

No

Write here

Estimate the recoverable damages

What are the total medical bills?

Tell us about your client

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Client name James

DOB 03.15.1984

DOL 01.05.2010

Select all that apply

Medical lien

General health insurance

Medicare/medicaid

Settlement Offers

No

Yes

What are the total medical bills?

Tell us about your client

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Client name James

DOB 03.15.1984

DOL 01.05.2010

Is there any additional coverage?

Yes

No

Carrier name

Policy limits

Policy number

Case type

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Choose one:

Motor vehicle accident (MVA)

Medical Malpractice

Work related injury

Premises liability

Nursing Home

Product defect

Vocational Assessment

Other

MVA prompt

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Additional info about MVA prompt case type

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How many claimants are there?

Plaintiff was not the driver:

Front seat passenger

Rear seat passenger

Not a passenger

Plaintiff was not rear-ended:

Side impact

Front end

T-bone

Rear end

Other

Plaintiff’s vehicle was not severely damaged:

Minimum damage

Moderate damage

Repair estimate of the property damage:

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OR

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Photos of the crash:

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Premises Liability

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Select all that apply

An ambulance was called to the address of the accident

Plaintiff went to the Emergency Room

Plaintiff received treatment within a week of the accident

Plaintiff was hospitalized after the accident

This is not a slip and fall

I have an incident or police report

I have photos or video of the accident

Adverse party disputes liability

I have filed a Complaint

Additional info about Premises Liability case type

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This is not a slip and fall, choose one:

Something fell on plaintiff

Negligent security

Dog bite

Battery

Other

After injury went to

ER

Urgent Care

Chiro

Doctor

Home

Attach incident or police report:

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Attach photos or video of the accident:

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Complaint:

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Product defect

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Select all that apply

Prior successful lawsuits exist regarding this product

Plaintiff has an expert report supporting liability ordered or completed

This case is a class action

This is a mass tort

Summary of how product deffective

Deffective product

Product defect expert report:

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Nursing Home Care

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Select all that apply

I won a prior settlement/lawsuit(s) against this Defendant

My state has a statutory cap on recovery

Decedent was not visited within 30 days of death

Nursing Home Claim Past Year

Additional info about Nursing Home Care case type

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Drop the file of expert report(s) in those cases:

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What is the dollar amount?

Summary

Med Mal

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Select all that apply

I do not already have an affidavit of merit or verbal confirmation that the medical treatment fell beneath the standard of care

An Expert written opinion on standard of care is available

My state has a statutory cap on medical mal practice damages

Additional info about Med Mal case type

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Attach Expert written opinion on standard of care

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What is the dollar amount?

Work related injury

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Additional info about Work related injury case type

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Attach incident report:

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Attach relevant documents:

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Attach photos or video of the accident:

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Attach other expert reports already on this case:

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Vocational Assessment

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Select all that apply

I have pre-injury Occupation

Plaintiff can’t perfom pre-injury occupation

I know annual sallary before injury

Wage loss claim?

Vocational Assessment

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Expert report type

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Other

Already have an Expert?

Expert report is due

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Date

Optional fields

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Expertpays is ready for your request

Firm contact

How did you hear about us?

Tell us about your client

Death case?

Tell us about your client

Client language

Tell us about your client

Tell us about your client & case

Case status

Attach complaint

Has the adverse party accepted liability?

Provide the at fault party's insurance carrier’s information:

Plaintiff still treating

Future Surgery Recommended?

Tell us about your client

Select all that apply

Settlement Offers

Tell us about your client

Is there any additional coverage?

Case type

Choose one:

MVA prompt

Select all that apply

Additional info about MVA prompt case type

Plaintiff was not the driver:

Plaintiff was not rear-ended:

Plaintiff’s vehicle was not severely damaged:

Repair estimate of the property damage:

Photos of the crash:

Premises Liability

Select all that apply

Additional info about Premises Liability case type

This is not a slip and fall, choose one:

After injury went to

Attach incident or police report:

Attach photos or video of the accident:

Complaint:

Product defect

Select all that apply

Product defect expert report:

Nursing Home Care

Select all that apply

Additional info about Nursing Home Care case type

Drop the file of expert report(s) in those cases:

Med Mal

Select all that apply

Additional info about Med Mal case type

Attach Expert written opinion on standard of care

Work related injury

Select all that apply

Additional info about Work related injury case type

Attach incident report:

Attach Witness Statement(s) or Deposition transcripts:

Attach OSHA or other reports of violations:

Attach relevant documents:

Complaint:

Attach photos or video of the accident:

Attach other expert reports already on this case:

Vocational Assessment

Select all that apply

Vocational Assessment

Expert report type

Please select the expert report you are looking for

Expert report is due

Optional fields