& DnMAND Pn'craGE. WomINGUPTHE Ca.sn. Website: Facsimile: (512) UT Can WnPcr CLE
|
|
- Louise Wade
- 8 years ago
- Views:
Transcription
1 WomINGUPTHE Ca.sn & DnMAND Pn'craGE 2014 UT Can WnPcr CLE J. Luke Dow Lew Oprrce or J. LurP Dow 2901-C Bee Cave Road Austin, Texas Telephone: (512) Facsimile: (512) Website:
2 This paper is intended to provide tips and guidelines in working up your personal i.rj,rry cases from intake through the demand package in order to maximize pre-suit settlement value. Even if the case is not settled and you end up in a lawsuit, you will at least have completed some of the necessary legwork in getting your case ready for trial. So either way, it makes sense to be thorough on the front end of your case. INTAKE Most people who end up in your office have never been through an accident or dealt with an insurance company. Some have no idea what to expect and many have unrealistic expectations. In any event, they are looking to you for guidance and help. Before meeting with a potential new client, I try to get them to send me as much information as possible so that I can review it before the meeting. This allows me to focus more on them while they are sitting in front of me rather than reading through documents. Having your paralegal or someone on your staff in the initial meeting gives him or her the opportunity to learn the case from the outset. Your paralegal will also get to know the person with whom they will be working. My paralegal usually takes better notes than I do and it gives me another set of eyes in evaluating the potential client and his/her case. Finally, it allows the client to get to know my paralegal and develop a level of trust with her. Although I try to work directly with the client after the initial meeting, I f,rnd that the client is more comfortable dealing with my paralegal when they've previously met in person. At the initial meeting, we try to gather as much information as possible. This includes witness information, the police report, list of treating doctors, lost wage information, photographs, property damage estimates, insurance information and claim numbers, past Page2
3 injuries, past claims, criminal history, health insurance info, etc. You cannot have too much information! In the intake, I am also evaluating the potential new client and her case. Over time I've learned that declining a case about which I have reservation(s) is good practice. If you are hesitant about a client or case, this reservation will probably not improve over time. If you decline the case, it is good practice to follow up with a rejection letter. Clrnxr Exppctarroxs I always want to make sure that the client and I are on the same page. To that end, I have a very frank discussion at the outset about their expectations regarding VALUE and TIME. Most people want to know "how much is my case worth" and "how long will it take". If you answer the first question in the initial meeting, good luck explaining that later on. Rather, I make sure that they understand there is no way to value the case at such an early stage and that any attempt to do so would be speculative at best and malpractice at worst. I try to explain the reality of injury cases in Texas and give them examples such as "paid vs. incurred" and medical malpractice caps (even if it's not a medical malpractice case). I avoid getting on my political soapbox and simply point out the reality of tort law in Texas. The point of this is to gauge their expectations and determine if I can meet those expectations. If I sense that I can never meet those expectations, I reject the case. We've all heard something like "my friend's cousin got rear ended in a parking lot, went to his chiropractor a few times, and his attorney got him $ 1 00k!" That' s great - feel free to go hire that lawyer. At best, these types of people will be unmanageable clients if their expectations remain unchecked. In my humble opinion, life's too short and money's not everything. Page 3
4 I try to outline the claims process and explain that it will take time. First, my office will not order the medicals until treatment is completed, which is 100% up to the medical professionals. Even when this is done it is at least a matter of months before we are in a position to settle. I explain that my goal is to get the insurance company to their very best offer and that only then can an informed decision be made on whether to take the offer or file suit. I let them know that if suit is filed, it could very well take over a year and possibly multiple years depending on the complexity of the case and/or injuries. I explain that I will do everything in my powff to get the case resolved as efficiently and effectively as possible, but I never guarantee a result or a timeline. I also try to follow this meeting up with a letter outlining the process, a sample of which is included in this paper. ClrrNt Pnrparurrox As we all know, medical non-compliance and gaps in treatment can cripple a case. I impress upon the client that every move they make, or fail to make, will be scrutinized and questioned. This is especially true with not showing up for appointments and not following medical orders. Any failure to follow medical advice and keep appointments is detrimental. If they simply can't avoid missing an appointment, they need to contact the provider beforehand and explain the reason. The client also needs to understand that from the moment the accident occurred through a verdict, they are susceptible to being monitored. This includes social media and blogging. I certainly research the potential defendant and they should expect the same from the insurance company and its attorneys. I urge them to exercise discretion and common sense in posting any information on Facebook, Twitter, etc... Page 4
5 Assuming I've decided to take the case during the initial meeting, I have the client sign a fee agreement, medical authorization and give them a lost wage verification form to take with them. I also have a medical provider list which is kept in the file. A11 of these forms are included in this paper. Finally, I tell the client to call/ my paralegal or myself with any questions and/or updates, but to certainly let us know when they have been released from treatment. OPENING AND WORKING THE FILE Polrcn Rpponr & Wlrxnss STATEMENTS Immediately after the initial meeting (assuming I've been retained), my paralegal and I go through a "client checklist" and assign action items between us. We try to order the police report the same day if the client doesn't already have it. If we are obtaining the report, we order a certified copy so that it is admissible if the case doesn't settle. Getting witness statements quickly is also important. Witnesses may move, die, forget, etc... Better to get this information established early. Obviously, we speak to the witnesses first and ensure that they are willing to cooperate and are favorable to us. The more things my office does on the front end, the less likely it will slip through the cracks. In addition to explaining how an accident occurred, witnesses may be able to tell you if the other person was using a cell phone or otherwise distracted. Besides witnesses to the accident, get a list of people who will later be able to testify regarding how the accident has affected the client's daily activities, work, hobbies, etc... These folks may eventually provide valuable evidence of the client's pain and impairment. This information may or may not be used in a demand package, but will prove invaluable at trial. Page 5
6 LBrrBns or RtpnnsENTATIoN It is best to fax a letter of representation out to the liability carrier the same day so that they no longer try to contact the client. Conversely, the client needs to know not to contact the liability carrier. I also set up a sub-file for UMAJIM and PIP and send letters of representation to these carriers. In the notice, I demand written rejection of UMfuIM and PIP benefits. Lruxs/SunRoGATIoN I find it helpful to keep certain items segregated from the rest of the file. I do this by creating a sub-file within the main file. This is especially true with liens and subrogation claims. I don't want to settle a case and disburse the money only to leam that a letter of protection was buried in the correspondence file. Also, it will save time to set up the Medicare and/or Medicaid claims early rather than waiting until the case settles. Further, you need this information to establish "paid vs. incurred". Set up the Medicare and Medicaid claims early. When setting up the Medicare claim, send the fee agreement and the client's HIPAA authorization with the initial letter. Also include a detailed list of the client's injuries. Both Medicare and Medicaid's information is included in this paper' Mnorcll, Rrconos & BIlls Once the client is finished with treatment, it's time to order the medical information. I emphasize that it is the client's responsibility to let me know when treatment has ended. For several reasons, I order medical bills and records in admissible form at this early stage. First, the adjuster will know that you intend to file suit in the event that the case is not resolved. Second, if you end up filing suit, you can file your affidavits early and trigger the Page 6
7 defendant's deadline to file contraverting affidavits to your bills sooner rather than later. Third, it prevents you from having to order the medicals twice in the event the case doesn't settle without a lawsuit. Finally, the affidavits spell out the "paid vs. incurred" figures that you will ultimately submit to a jury. N,lRRarryBs In some cases, you may need to obtain medical information that is not included in the records or bills. For instance, if you are asserting a claim for future medicals, this most likely will not be adequately addressed in your client's past medical records or bills. In this situation, you will need to have at least one narrative completed by a physician to support the claim. Otherwise, this element of damages will not be considered by the adjuster. The same goes for future lost wages if your client can't work but has no documentation to that effect' A request for a narrative is included in this paper. PHorocRapus Pictures of property damage and injuries are very compelling and may increase the value of your client's case in some circumstances. Assuming the photos help the case, they obviously need to be a part of the demand package. If your client has a visible injury, have them take photos of the injury at its early stages and as it improves where it is appropriate. This is especially true if you are making a claim for disfigurement. It is also useful to show objective injury, pain and suffering and possibly impairment. GexnRq.L You can also conduct a background check of the other driver to determine his criminal background and driving offenses or suspended license. A preliminary check can be made on PageT
8 A more comprehensive background check may necessitate an investigator. If a commercial vehicle was involved, obtain the DOT inspection report' your client may have additional medical bills such as prescriptions or deductibles that are not readily apparent from the medical records. Your client's laptop may have been destroyed in the accident. you can gather most of this information directly from your client' Before filing a lawsuit, you typically don't know the other party's limits of liability or whether they have an umbrella policy. I'm aware of at least one service that assists in finding this information. A good investigator may also find it' When it comes to dealing with the adjuster, I try to be courteous and friendly and avoid hostility. I try to find the things upon which we agree and establish some conlmon ground' When we disagree on an issue, I try to address it without being ugly or rude' If we are unable to settle the case and I need to file a lawsuit, I send a courtesy copy of the petition to the adjuster. I don't believe that treating the adjuster poorly or trying to bully them will advance my client's cause. In fact, I believe that it may harm my client's cause' I try to advance my client's interests rather than my own ego. When it comes to giving a recorded statement, I almost always decline. However, there are a few situations in which I will allow it. For instance, if the case needs an extra push and I,ve got a great client, I will consider it. In those rare situations, I get an agreement beforehand that the insurance company will provide a copy of the statement (either recorded or transcribed) immediately afterwards. I also prepare my client just as if we were preparing for a deposition. I know that this goes against the grain of conventional wisdom, but I will occasionally allow it under these limited circumstances. If the client is adequately prepared and I secure a transcript, I'm not worried about issues of consistency in future testimony' Page 8
9 THE DEMAND PACKAGE When the time comes to send the demand, visit with the client about the amount of the demand given the facts of the case, the injuries and the information that has been obtained. Obtain their consent to the amount of the initial demand, but also explain that the demand is just a starting point. Explain the negotiation process and that the goal is to get the best offer possible and that the first offer is rarely the last. I let them know that once I get the "best" offer, I will break it down completely to determine their net recovery. That way they can make an informed decision about settling or filing suit. If it's a clear Stowers situation, I may explain that unless the demand is met, we will simply file a lawsuit. In the initial demand package, try to be reasonable and not overreach. For instance, if the client has $15, in medicals and has fully recovered from her injuries, and there are no aggravating circumstances, don't demand $500, t think that sets false expectations for the client and makes you seem unreasonable or even incompetent to the adjuster. This scenario would most likely result in a no-offer or an offer of $250.00, which will in turn upset the client. Why stir the pot unnecessarily? Further, if it is notastowers situation, don't include Stowers language in the demand. Again, this will do nothing to advance the client's case and will only hurt your credibility. However, if the case is a Stowers situation, make sure that all of the Stowers requirements are met. I have included what I believe to be the appropriate Stowers language in this paper. In your letter, first establish liability with the police report and witness statements. If there is a question about liability, address it early. If the client bears some percentage of Page 9
10 responsibility, acknowledge this fact. This approach may go against every fabric of your being, but I believe it establishes credibility. The demand letter is not admissible anyway. Once you've discussed liability, go through your client's damages. Include medical records, bills, lost wage verification, photographs and narratives. If the case merits a life care plan, by all means include it. The adjuster's job is to close files promptly and efficiently. Try to help them reach their best offer by providing them with the information that enables them to do so. If you are able to settle without filing a lawsuit, that's great. If you are unable to settle, wish the adjuster well and file suit. You will most likely deal with this person again in the future, so try to establish and maintain a good working relationship' Good luck and I hope that this paper is of some benefit to you! ATTACHMENTS TO THIS PAPER: New CltpNT LIST Fee AcnepMENT Meprcel AurHoRIzRttoN Losr WecE VERIFICATIoN FoRM Meorcel PRovroeR Ltsr NBw CIIeNT LETTER Meorcene CoNrecr INno Meorcenn ConnespoNDENCE Coven Sneer Mporcerp CoNrecr INro Meorcnr Brr-rNc Aprroevrr (Tex. Crv PRacr & Rpv Cooe SEcrtoN tno Escoaooo) MEprcel Reconos Arrtonvtr (Texas Rules op EvloeNcE 902(10)(s)) NeRRertve Rreuesr Srowoas LaNcuncr Page 10
11 NEW CLIENT CHECKLIST Fee Agreement Medical Authorization Lost Wage Verification Client Info Client letter Client List (w/ DOB) Police Report Photos LOR Medicals il Affidavits Medicals dout Affi davits LOP Demand to be sent File Suit i No Demand Medicare/Medicaid Notice Liens/Subrogation PIP UMruIM
12 FEE AGREEMENT If no settlement is obtained, client will not owe a legal fee or expenses. CLIENT AGE PARENT/REPRE SENTATIVE STREET ADDRESS CITY, STATE, ZIP PHONE: Home: Law Office of J. Luke Dow 2901 Bee Cave Road, Box C Austin, Texas s I luke@lukedow.com PHONE: Work/CelUPager: CASE TYPE: Injured person is: Adult, signing for self Disabled adult or minor, signed by parent/representative Deceased, signed by authorized representative LEGAL REPRESENTATION. Client hires the Law office of J. Luke Dow (JLD) to pursue a clalm for injuries *dd"@nceorotherlegalbreach.clientauthorizesjldtopursueavailablesourcesof recovery * no deems n"""riury. Client ugr..r that JLD may associate additional lawyers/firms to assist with this case and Client agrees to thosharing of f."r between lawyers. Client understands the terms herein apply to other lawyers associated on this case and that association of other lawyers or law firms does not increase the amount of the attorney fee due to lawyers on successful resolution of the claim. COOPERATION. Client agrees to be available for consultation, investigation, deposition, trial preparation, *a ao necessary work as JLD directs and do nothing to impair the value of the case. JLD agrees to use his best effort and skill in pursuing this case but do not guarantee a specific result. Client appoints JLD as his/her afforneys-in-fact to p."r"rrt claims and/or endorse checks or drafts representing settlement or judgment proceeds to expedite disbursement. 33 l/3% LEGAL FEE If no settlement is obtained, client will not owe a legal fee or expenses. If JLD obtains settlement *..ou"ry for Client, Client will pay to JLD thiny-three percent (33 ll3%) of the total gross recovery. Expenses wiit Ue paid out of client's recovery. If the case cannot be resolved short of trial, then the fee increases to forty percent (40%) of the total gross recovery. CASE EXPENSES & AUTHORIZATION. JLD will not ask client for expense money during the t unatirg of th..a... Cus..osts and expenses will be advanced by JLD. Examples of typical expenses include court filing fees, investigation, court reporters, medical records, interest on any money JLD bonows for expenses, ixpert witness fees, air fare,.tr. tf a recovery is obtained, Client will reimburse JLD for these expenses from Client's share of the total recovery. TERMINATION OF THIS AGREEMENT. If this agreement is terminated before the case is resolved, client g*"r JLD. tt* ugai.rrt u.ry subsequent recovery as allowed by Texas law. JLD may withdraw from iepresentation of Client if they determine prosecution of the claim is not practicable.
13 MISCELLANEOUS. Client has read this agreement (or has had it read to himlher) and agrees to be bound by these terms. Any modifications in the terms of this agreement shall be typewritten or handwritten in the margin below and initialed by both parties. LIMITED POWER OF ATTORNEY. JLD is hereby granted a limited power of attomey so that JLD may have full authority to prepare, fully execute, sign and file all legal instruments, pleadings, drafts, authorizations, and PIP/JvledPay applications as shall be reasonable and necessary to complete JLD's representation including Client's personal injury and first party insurance claims as fully as Client could do so in person. This expressly includes the right to sign Client's name to insurance company drafts or checks or any other negotiable instruments proferred on behalf of defendant herein in full or partial settlement of Client's personal injury and first party insurance claims. LAW OFFICE OF J. LUKE DOW Date I CLIENT OT CLIENT'S REPRESENTATIVE Date _l I
14 I hereby authorize,,to disclose my individual identifia6lehealthinfoffihichmayincludeinformationasdescribedbelow, which may include information concerning communicable diseases as such as Human Immunodeficiency Virus 1,.HIV,') and Acquired lmmune beficiency Syndrome ("AIDS"), mental illness (except for psychoiherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, o, ury other such related information. I undeistand that this authorization is voluntary and I may refuse to sign inis information. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. I understand that this information may be subject to redisclosure and no longer protected. I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or health care provider, the release information may no longer be protected by federal and state privacy regulations. Patient Name Date of Birth Social Security Number Date(s) of Service (if known) Description of information to be released (check all EFace Sheet trradiology Repofis EDischarge Summary Elaboratory Reports trhistory & Physical EConsultation Reports EOperative RePorts EPathology Reports EDiagnostic RePorts The purpose of the disclosure is for the following: tr Patient Request: (type of disclosure) Attorney The information described herein will be sent to the following address: that apply) ORadiology Films (lmaging DePt.) OBilling Records (Patient Financial Services) OEmergency Room EOther: Name Address I understand that this authorization will expire 180 days from otherwise specifu. I desire this authorization to be in effect until the date of this authorization unless I I further understand that I may revoke this authorization at any time by notifuing J. Luke Dow at 2901 Bee Cave Road, Box C, Austin, t"*u, 78746,and the above stated health care provider in writing. I also understand that the written revocation must be signed and dated with a date that is later than the date of this authorization. The revocation will not affect any actions taken before the receipt of the written revocation' Signature Date Printed Name of Patient's Representative A COPY OF THIS AUTHORIZATION SHALL BE VALID AS THE ORIGINAL
15 LOST WAGE VERIFICATION Employer: Address: Phone: Employee: Occupation/Title: Length of Employ: Hours per week: Wage: per Hour/Week/Month/Year (Circle One) Total time missed: Total Lost Wages: Other lost benefits: Employer Printed Name: Employer Signature: Employer Title:
16 MEDICAL PROVIDER LIST \' clatm No: o4osi2o431i2 Please list all of the ohvsicians that vou are curre with Name: Address: Name: Address: Phone: Phone: Name: Address: Name: Address: Phone: Phone: Name: Address: Name: Address: Phone: Phone: Name: Address: Name: Address: Phone: Phone: Name: Address: Name: Address: Phone: Phone:
17 Law OpptcP or J. LurB Dow ATTORNEY AT LAW THE COMMISSIONERS HOUSE AT HERITAGE SQUARE 29Ol BPP.CnvE RoeD, Box C AUSTIN, TEXAS Board Certifred - Personal Injury Trial Law Texas Board of Legal Specialization Telephone: (512) Facsimile: (512) June28,2014 Mr. xxxxxxxxxxxxxx 123 Road Austin, Texas Re: Claim No.: Our Client: Your Insured: Date of Loss: xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx Dear xxxxx: I enjoyed visiting with you and appreciate the opportunity to represent you in the above_referenced matter.- Although I will contact you with updates as yow case progresses, prease feel free to contact me at any time with questions, additional information, etc..., either via phone or , which is luie@lukedow.com. My website can be accessed at Most people are unfamiliar with the claims/litigation process in general, and more specifically with the nuances,urrorrnding a personal injury caje' Let me therefore take this opportunity to give you a general outline of what to expect' CLAIMS PROCESS This is the phase of the case before a lawsuit is filed, where both sides are attempting to settle the case without expending the time and expense of litigation. If a_ claim has not already been set up with the insurance company or other appropriate party, I witl take-care of this' Either way, I will send a letter of represeniation to the carrier once I've been retained by you' Once you finish any and all medical treatment you ale receiving, please call me to let me know that you've been released from treatment. This is very important as it is the only way I'll know to begin ordering your medical records and bils. - once I've received all records and bills, and any additional information such as lost *ages you've incurred, photographs, property damage' etc^"' I will prepare a demand package to be sent to the insurance company' During this phase of the case, my goal is to g.t th" verf best offer that the other side is willing to make' Once this is done' I,ll be able to give you a breakdown based on the offer. If you choose to reject the offer, the next
18 step is to file a lawsuit and begin the litigation process. This is a much more formal process and is governed by the Texas Rules-of Civil Procedure and the Texas Rules of Evidence' LITIGATION Once a lawsuit is filed, I,ll be dealing with a lalvyer who represents the defendant as opposed to the claims adjuster. Dr;t;; lalsu.it,.both sides typically exchange written discovery which will require your assistince. This is important becau.se there are strict times within which discovery needs ao *.*.i"j, and the failure to do so will normally result in the waiver of objectior. io.*. at best, ani dismis'al of your case at worst' Therefore' it is imperative that you cooperate with my office in answering the discovery questions' DepositionsusuallyfollowthewrittendiscoveryifnecessarY,andthenamediationin which the parties attempt to settle the case. If the case doesn't settle at the mediation, the last step is a trial before a judge and/or jury. fo g"t u tu" worked up and tried to a.jury will usually take one (1) year or more, depending on the pa?iculars of the case' Unless one side files an appeal' the jury verdict will be the ending point of the case' Again, this is the general course of events'.some cases may settle quickly without discovery or depositions, and,oln.,*y-tui.,rurt*tially longer' Although most cases settle before trial, a r.uti p"r."ntage will require trial to reach conclusion. In any event, I appreciate the opportunity- to represent you and look forward to working with you. I hope the foregoing gives Vir.or. idea of what to Lxpect. Nevertheless' feel free to contact me at any time with questions you may have' Sincerely, J. Luke Dow
19 MEDICARE To set up claim: 85s NGHP PO Box Oklahoma City, Oklahoma Fax (405) http :i/go.cms. gov/attorney SEND FEE AGREEMENT AND HIPAA AUTHORIZATION
20 cg.rm &n.llb md Racovry NGHP Correspondence Cover Sheet Beneficiary's Name HIC#: Date of lncident: Case ID#:.(can be found on Rights and Responsibilities leuer) This cover sheet is for your use when mailing or faxing in correspondence to the Benefits Coordination & Recovery Center (BCRC). Please retain a COPY of this cover sheet for any future correspondence. The information above will ensure accuracy when handling your case documentation. Please indicate the type of correspondence you are submitting to the BCRC to facilitate routing. Check all that apply: tr Check I Settlement information! Retainer agreement or other authorization documentation E Other Note: A Conditional Payment Letter is sent automatically, as soon as the information is available. Separate requests for initial Conditional Payment Amounts will not make Conditional Payment information available sooner. In order to accurately associate claims to your case, please include a description of the injury. (i.e.: Knee, Physical Therapy, Slip and Fall, Lumbar Injury...) Submit correspondence to the BCRC address listed below: Liability Insurance, No-Fault Insurance, Workers' Compensation : NGHP PO Box oklahoma City, OK 731 l3
21 MEDICAID TMHP PO Box Austin, Texas Fax (512)
22 MEDICAL BILLING RECORDS AFFIDAVIT (ANY AND ALL RECORDS FROM TO THE PRESENT) RECORDS PERTAINING TO: XXXXX; DOB: XXXX; SSN. *** THE STATE OF TEXAS, COUNTY OF TRAVIS BEFORE ME the undersigned authority, personally appeared who being by me duly sworn, deposed as follows:. I am of sound mind, capable of making this My name is affidavit, and personally acquainted with the facts stated herein. I am the person who provided these services or the custodian of records showing the services provided and charges made. Attached hereto and incorporated herein by reference is an itemized statement of the services provided to NETWORK/UMC@BRACKENRIDGE for the date(s) of service from to The total amount charged for these services is $ The total amount paid as of this date is $ The total amount unpaid but still owed as of this date is $-. -. At SETON HEALTHCARE The amounts paid and/or unpaid but still owed for the services set forth were reasonable at the time and place the services were provided, and the services were necessary for the treatment of "The attached documents are kept by me or someone under my supervision in the regular course of business, and it was the regular course of business of myself or an employee or representative of myself with knowledge of the act, event, condition, opinion, or diagnosis reiorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time or reasonably soon thereafter. The records attached hereto are the original or exact duplicates of the original." AFFIANT SWORN TO AND SUBSCRIBED before me on this,2014. day of NOTARY PUBLIC, State of TEXAS My Commission Expires Print Name
23 MEDICAL RE,CORDS AFFIDAVIT (ANY AND ALL RECORDS FROM To THE PRESENT) RECORDS PERTAINING TO: JOHN DOE; DOB: ; SSN: *** THE STATE OF TEXAS, COUNTY OF TRAVIS BEFORE ME the undersigned authority, personally appeared who being by me duly sworn, deposed as follows: My name is. I am of sound mind, capable of making this affidavit, and personally acquainted with the facts stated herein. I am the custodian of records of SETON HEALTHCARE BRACKENRIDGE HOSPITAL. Attached hereto are of records from SETON HEALTHCARE 5y5rEM/UMC@BRACKENRTDGE HOSPITAL. These pages of records are kept by SETON HEALTHCARE SYSTEMruMC@BRACKENRIDGE -pages HOSpITAL in the regular course of business, and it was in the regular course of business of SETON HEALTHCARE BRACKENRIDGE HOSPITAL fot AN employee or representative of SETON HEALTHCARE SYSTEM/UMC@BRACKENRIDGE HOSPITAL, with knowledge of the act, event' condition, opinion, or diagnosis, recorded to make the record or to transmit information thereof to be included in such records; and the record was made at or near the time or reasonably soon thereafter. The records attached hereto are the original or exact duplicates of the original' AFFIANT SWORN TO AND SUBSCRIBED before me on this day of NOTARY PUBLIC, State of TEXAS PrintName My Commission ExPires
Lowcountry Injury Law
Lowcountry Injury Law 1917 Lovejoy Street Post Office Drawer 850 Beaufort, South Carolina 29901 Personal Injury Phone (843) 524-9445 Auto Accidents Fax (843) 532-9254 Workers Comp DanDenton@Lawyer.com
More informationSettling Your Injury Case...
Settling Your Injury Case... Without a Lawyer How to maximize the value of your claim under $10,000 The information provided in this report is for informational purposes only. Shulman DuBois LLC does not
More informationATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT
STATE OF GEORGIA ATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT I,, with a Social Security Number of the undersigned, do hereby retain the Ramos Law Firm, LLC, located
More informationMEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE
MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE Complete this form if you are a MEDICAL BENEFITS SETTLEMENT CLASS MEMBER seeking to exercise a BACK END LITIGATION OPTION. In addition to
More informationTo help us provide you the best possible care, please fill out the following information.
WELCOME TO OUR TREATMENT CENTER! To help us provide you the best possible care, please fill out the following information. Demographic Information: Name: DOB: Gender: M or F SSN: How long have you lived
More informationMEDICAL LIEN CONTRACT. Date Patient Name Patient Date of Birth Date of Loss
MEDICAL LIEN CONTRACT Date Patient Name Patient Date of Birth Date of Loss Payment to Provider: I, ( Patient ), hereby authorize and direct you ( Attorney ), to pay directly to ( Provider ) AND/OR TO ANY
More informationParsonage Vandenack Williams LLC Attorneys at Law
MEDICAL RECORDS ACCESS GUIDE NEBRASKA Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS RESPONDING
More informationClaim Information. Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address:
Page 1 of 12 Claim Information Date of Accident Primary(Your Insurance) Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address:
More informationInformation for Worker s Compensation Clients
Information for Worker s Compensation Clients Overview of the Worker s Compensation Act Indiana Worker s Compensation cases are governed by a State law known as the Worker s Compensation Act. The legislature
More informationCRIMINAL DEFENSE AGREEMENTS
5/6/13 CRIMINAL DEFENSE & CIVIL LITIGATION AGREEMENTS LLOYD M. CUETO LAW OFFICE OF LLOYD M. CUETO P.C. 7110 WEST MAIN STREET BELLEVILLE, ILLINOIS 62223 (618) 277-1554 CRIMINAL DEFENSE AGREEMENTS HOW TO
More informationCONTINGENCY FEE EMPLOYMENT AGREEMENT BETWEEN ATTORNEY AND CLIENT
CONTINGENCY FEE EMPLOYMENT AGREEMENT BETWEEN ATTORNEY AND CLIENT THIS AGREEMENT is entered into as of this Day of, 2009 by and between JOSEPH L. KASHI, Attorney at Law, hereinafter called "Attorney" and,
More informationDear Sir/Madam: Thank you for this opportunity to be of service, and please do not hesitate to contact our claims center if you have any questions.
Dear Sir/Madam: Kindly be advised that National Adjustment Bureau has been authorized by underwriters to adjudicate your claim. We look forward to resolving your claim in a prompt and equitable manner.
More informationATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A.
ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) 772-2644 Lauderdale-By-The-Sea, Florida 33308 Fax: (954) 772-2845 attorneysjoannhoffman@gmail.com AUTHORIZATION
More informationBlyss Chiropractic, 111 SW Columbia, Suite 100, Portland, OR 97201
Patient Name: Date of Birth: Page 1 of 7 Patient Name: Date of Birth: Page 2 of 7 Patient Name: Date of Birth: PAIN DRAWING SYMPTOM RATING SCALE Ache
More informationInformation or instructions: Contingency fee agreement for personal injury cases PREVIEW
Information or instructions: Contingency fee agreement for personal injury cases 1. The following form is a written contingency fee agreement that may be used to employ the attorney to handle the personal
More informationWARNKEN, LLC Attorneys at Law 2 Reservoir Circle Suite 104 Pikesville, Maryland 21208-1391 443-921-1100 443-921-1111 (fax) www.warnkenlaw.
WARNKEN, LLC Attorneys at Law 2 Reservoir Circle Suite 104 Pikesville, Maryland 21208-1391 443-921-1100 443-921-1111 (fax) www.warnkenlaw.com Starting Your Workers Compensation Case Dear Potential Client:
More information** To download a copy of this paper, go to http://www.coplancrane.com/firm-news/. All the attachments to the paper are bookmarked within the pdf.
THE DEMAND PACKAGE FOR GENERAL PRACTITIONERS: FIVE ESSENTIAL CONSIDERATIONS TO RESOLVING A PERSONAL INJURY CAR CRASH CASE WITHOUT FILING A LAWSUIT. BEN CRANE COPLAN & CRANE, LTD. 1111 WESTGATE STREET OAK
More informationMEDICAL RECORDS ACCESS GUIDE IOWA
MEDICAL RECORDS ACCESS GUIDE IOWA Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS Iowa...1 Patient
More informationSTANDARD CONTINGENT FEE REPRESENTATION AGREEMENT FOR INDIVIDUALS
Notice: This Agreement is not valid unless signed and accepted by an officer of The Feldman Law Firm, P.C., who will make the sole decision whether to accept your case. This Agreement may be digitally
More informationReleasing Information
Releasing Information There are 3 kinds of release situations now: our original Release of Information and it s uses under Colorado Law and Professional Ethical Standards; HPAA s Consent to release information
More informationFIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COURT TERM: NO.
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA PLAINTIFF(S) v. DEFENDANT(S) CIVIL TRIAL DIVISION Compulsory Arbitration Program COURT TERM: NO. Defendant s Interrogatories
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationHow to Hire a Personal Injury Attorney
How to Hire a Personal Injury Attorney When you hire a personal injury attorney, you need to weigh your options carefully. This report was designed to help you address some of the issues you will face
More informationVIRGINIA ACTS OF ASSEMBLY -- 2015 SESSION
VIRGINIA ACTS OF ASSEMBLY -- 2015 SESSION CHAPTER 585 An Act to amend and reenact 38.2-2206 of the Code of Virginia and to amend the Code of Virginia by adding in Article 7 of Chapter 3 of Title 8.01 a
More informationPIERCE COUNTY DISTRICT COURT 930 TACOMA AVE S, Room 239, TACOMA, 98402. Small Claims Information
930 TACOMA AVE S, Room 239, TACOMA, 98402 Small Claims Information A Small Claims case can be filed for the recovery of money only. This amount cannot exceed $5,000. LEGAL ADVICE The clerk will assist
More informationThe establishment of the attorney-client relationship involves two elements: a person seeks advice or assistance
SECTION 1 Establishing the Attorney-Client Relationship The establishment of the attorney-client relationship involves two elements: a person seeks advice or assistance from an attorney; and the attorney
More informationName: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation:
You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your
More informationTHE IMPACT OF HIPAA ON PERSONAL INJURY PRACTICE
THE IMPACT OF HIPAA ON PERSONAL INJURY PRACTICE JEFFREY B. McCLURE Andrews & Kurth L.L.P. Copyright 2003 by Jeffrey B. McClure; Andrews & Kurth State Bar of Texas 19 TH ANNUAL ADVANCED PERSONAL INJURY
More informationCONTINGENCY FEE CONTRACT
CONTINGENCY FEE CONTRACT THIS IS AN AGREEMENT between, hereafter referred to as "Client," and the Law Offices of, PLC, hereafter referred to as "Attorney." 1. Matter Covered: Client retains Attorney to
More informationConroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.
Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics
More informationMAXIMIZE YOUR PERSONAL INJURY SETTLEMENT
MAXIMIZE YOUR PERSONAL INJURY SETTLEMENT Part I: Find Insurance Coverage: Look at Accident Report & Write Letters People injured in a car accident in Florida should easily be able to locate car insurance
More informationPHENIX CITY SPINE & JOINT CENTER
PHENIX CITY SPINE & JOINT CENTER Name: Street Address: Please list ALL medications City: State: Zip: Home Phone: Cell #: Name Of Medication Dosage/ Strength Frequency Date Started Cell Phone Carrier: Race:
More informationTable of Contents. 1. What should I do when the other driver s insurance company contacts me?... 1
Table of Contents 1. What should I do when the other driver s insurance company contacts me?... 1 2. Who should be paying my medical bills from a car accident injury?... 2 3. What should I do after the
More informationCompulsory Arbitration
Local Rule 1301 Scope. Compulsory Arbitration Local Rule 1301 Scope. (1) The following civil actions shall first be submitted to and heard by a Board of Arbitrators: (a) (b) (c) (d) Civil actions, proceedings
More informationSUBCHAPTER 10L INDUSTRIAL COMMISSION FORMS SECTION.0100 WORKERS COMPENS ATION FORMS
SUBCHAPTER 10L INDUSTRIAL COMMISSION FORMS SECTION.0100 WORKERS COMPENS ATION FORMS 04 NCAC 10L.0101 FORM 21 AGREEMENT FOR COMPENSATION FOR DISABILITY (a) (Effective until July 1, 2015) The parties to
More informationPREVIEW. 1. The following form may be used to file a personal injury lawsuit.
Information or instructions: Plaintiff's original petition-auto accident 1. The following form may be used to file a personal injury lawsuit. 2. It assumes several plaintiffs were rear-ended by an employee
More informationGuide. to Recovery Under The Illinois Workers Compensation Act. The Injured Employee s
The Injured Employee s Guide to Recovery Under The Illinois Workers Compensation Act Prepared By: Romanucci & Blandin, LLC 33 North LaSalle Street, 20th Floor Chicago, Illinois 60602 Toll Free: 888.458.1145
More informationLAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.
LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME
More informationFURR & HENSHAW. http://www.scmedicalmalpractice.com
FURR & HENSHAW http://www.scmedicalmalpractice.com 1900 Oak Street Post Office Box 2909 Myrtle Beach, South Carolina 29578 (843) 626-7621 (800) 849-2525 fho@sc.rr.com and 1534 Blanding Street Columbia,
More informationCONTINGENT FEE CONTRACT
CONTINGENT FEE CONTRACT STATE OF TEXAS COUNTY OF BEXAR General Terms & Nature of Case THIS IS AN AGREEMENT between THE GORDON LAW FIRM, P. C., (hereinafter referred to as "the Firm"), whose principal office
More informationHow To Prove Guilt In A Court Case In Texas
CAUSE NO. 02-01125-J CHARLES DURHAM IN THE 191ST DISTRICT COURT VS. LARVAN PERAILTA DALLAS COUNTY, TEXAS PLAINTIFF S MOTION TO RECOVER EXPENSES OF PROOF TO THE HONORABLE COURT: Comes Now, Charles Durham,
More informationMichigan Property & Casualty Guaranty Association P.O. Box 531266 Livonia, Michigan 48153-1266 Phone: (248) 482-0381
Michigan Property & Casualty Guaranty Association P.O. Box 531266 Livonia, Michigan 48153-1266 Phone: (248) 482-0381 Dear Claimant: The Michigan Property & Casualty Guaranty Association ("the MPCGA") is
More informationPROFESSIONAL COUNSELSM
PROFESSIONAL COUNSELSM ADVICE AND INSIGHT INTO THE PRACTICE OF LAW Lawyers Toolkit 3.0: A Guide to Managing the Attorney-Client Relationship A CNA PROFESSIONAL COUNSEL GUIDE FOR LAWYERS AND LAW FIRMS The
More informationPrepared by: Barton L. Slavin, Esq. 212-233-1010 Web site: www.nycattorneys.com
Prepared by: Barton L. Slavin, Esq. 1. Identify Insurance Company - On the Police Report there is a three digit code that identifies the insurance company for a vehicle. The following link will take you
More informationIN THE COMMON PLEAS COURT, PREBLE COUNTY, OHIO
IN THE COMMON PLEAS COURT, PREBLE COUNTY, OHIO IN THE MATTER OF THE CIVIL AND CRIMINAL LOCAL RULES: ENTRY The following local rules are adopted to govern the practice and procedures of this Court, subject
More informationLegalFormsForTexas.Com
Information or instructions: acknowledgment Personal injury settlement statement and client 1. The following form may be used as part of a personal injury settlement. 2. The form is a disclosure statement
More informationAPPENDIX 2A Sample Initial Letter
APPENDIX 2A Sample Initial Letter Dear [name]: Re: Motor Vehicle Accident Please read this letter carefully and retain it in your file, as it contains important information about your claim and the basis
More informationCLIENT INFORMATION SHEET CITY: STATE: ZIP: DOB: SEX: E-MAIL ADDRESS: EMPLOYER: PHONE ADDRESS: FELONY CONVICTIONS?
CLIENT INFORMATION SHEET DATE: NAME: REFERRED BY: ADDRESS: CITY: STATE: ZIP: PHONE: (H) (EMERG) (CELL) DOB: SEX: E-MAIL ADDRESS: SS#: SPOUSE EMPLOYER: PHONE ADDRESS: OCCUPATION: WEEKLY EARNINGS: FELONY
More informationMEDICAL RECORDS ACCESS GUIDE MICHIGAN
MEDICAL RECORDS ACCESS GUIDE MICHIGAN Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS Michigan...1
More informationCalifornia Life Settlement Qualification Form
PERSONAL INFORMATION California Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured
More information(404) 919-9756 david@davidbrauns.com www.davidbrauns.com
You are probably reading this guide because you were recently in an automobile accident. Now you are faced with some difficulties. The tasks of managing your care and your insurance claim can be confusing
More informationOne Third Contingent Fee Agreement with Waiver of Sliding Scale
Appendix II One Third Contingent Fee Agreement with Waiver of Sliding Scale, 2008 NAME OF CLIENT: DATE OF INJURY: JACOBS, GRUDBERG, BELT, DOW & KATZ P.C. ATTORNEY CONTINGENT FEE AGREEMENT WITH WAIVER OF
More informationNEGOTIATING WITH MEDICARE AND MEDICAID
NEGOTIATING WITH MEDICARE AND MEDICAID I. MEDICARE PROVIDES HEALTHCARE COVERAGE A. Persons 65 Years Old and Older B. Certain Disabled Persons under 65 C. Persons with End-Stage Renal Disease II. MEDICARE
More informationTHE TOP 10 QUESTIONS YOU SHOULD ASK YOUR CAR ACCIDENT LAWYER
THE TOP 10 QUESTIONS YOU SHOULD ASK YOUR CAR ACCIDENT LAWYER? Introduction After six straight years of decline, the National Highway Traffic Administration (NHTSA) reports that auto accidents, injuries
More informationTwo Sample Engagement Letters (with optional notices)
NOTE: This material is intended as only an example which you may use in developing your own form. It is not considered legal advice and as always, you will need to do your own research to make your own
More informationACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE
ACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE By signing this document, I acknowledge that I have received a copy of Western Dental s Joint Notice of Privacy Practices. Name
More informationUTAH. Past medical expenses may be recovered. Plaintiffs must show that they have been injured and,
UTAH Rick L. Rose Kristine M. Larsen RAY QUINNEY & NEBEKER P.C. 36 South State Street, Suite 1400 P.O. Box 43585 Salt Lake City, Utah 84111 Telephone: (801) 532-1500 Facsimile: (801) 532-7543 rrose@rqn.com
More informationMEDICAL MALPRACTICE INTERVIEW
How did you hear about our office? MEDICAL MALPRACTICE INTERVIEW Sign-Up Date: Date of Surgery: Medical Clinic Name: Telephone # Area of the Body: CLIENT S INDEX INFORMATION Were you the patient? Yes (
More informationAmerican Board of Professional Liability Attorneys *ABA Accredited Organization
MEDICAL PROFESSIONAL LIABILITY Applicant s Firm _ Street_ City _ State _ Zip _ Business Phone _ Fax E-Mail Address _ State of Principle Practice _ Other states where you practice _ Attorney Registration
More informationT RUST ACCOUNT I NTERPLEADER P ROCEDURES AND PUBLISHED BY THE OKLAHOMA REAL ESTATE COMMISSION
T RUST ACCOUNT AND I NTERPLEADER P ROCEDURES PUBLISHED BY THE OKLAHOMA REAL ESTATE COMMISSION Trust Account and Interpleader Procedures Revised July, 2005 PUBLISHED BY THE OKLAHOMA REAL ESTATE COMMISSION
More informationWHAT YOU NEED TO KNOW ABOUT YOUR CAR WRECK CASE PAGE 1
WHAT YOU NEED TO KNOW ABOUT YOUR CAR WRECK CASE PAGE 1 GREENVILLE FOUNTAIN INN 330 East Coffee Street 218 South Main Street Greenville, South Carolina 29601 Fountain Inn, South Carolina 29644 (864) 601-9048
More informationCIVIL PRACTICE AND PROCEDURE GARNISHMENT CHAPTER 77
CIVIL PRACTICE AND PROCEDURE GARNISHMENT CHAPTER 77 77.01 Right to writ of garnishment.--every person or entity who has sued to recover a debt or has recovered judgment in any court against any person
More informationJ. Richard Lilly, M.D., A.B.F.P., & Associates, P.C.
J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. PATIENT REGISTRATION - Please PRINT Clearly Patient Name First Middle Last Date of Birth Age Home Address Apt. No. City State Zip code Occupation Social
More informationUNDERSTANDING YOUR PROPERTY DAMAGE CLAIM
UNDERSTANDING YOUR PROPERTY DAMAGE CLAIM A LET US EMPOWER YOU This brochure will empower you with the knowledge and tools necessary to complete your own property damage claim. One of the biggest inconveniences
More informationPractice Resource. Retainer agreement and information. Personal injury contingent fee. Dear [client name]: Accident of [date of accident]
Practice Resource Retainer agreement and information Personal injury contingent fee Dear [client name]: Re: Accident of [date of accident] Thank you for asking my law firm to help you with your claim against
More informationDid the motor vehicle accident in which you were injured or personal injury occur in Maricopa County? Yes No
Welcome to Spooner Physical Therapy! We understand that you have been injured in a motor vehicle accident or other 3 rd party responsible personal injury situation. It is our goal at Spooner Physical Therapy
More informationTEXAS FAIR PLAN PRODUCER REQUIREMENTS AND PERFORMANCE STANDARDS
Producer Requirements Page 1 TEXAS FAIR PLAN PRODUCER REQUIREMENTS AND PERFORMANCE STANDARDS The following Texas FAIR Plan Association ( Association ) requirements and producer performance standards (
More informationFlorida Workers Compensation Settlements
DENNIS A. PALSO workers compensation board certified DENNIS A. PALSO, P.A. ATTORNEYS AT LAW Gateway Pines Executive Park 710-94 th Avenue North Suite 309 St. Petersburg, Florida 33702 Telephone (727) 578-5911
More informationNj Victims of Crime Compensation Office
Nj Victims of Crime Compensation Office Claim Information and Application Instructions New Jersey has a Crime Victim s Compensation Fund to help with costs related to injuries received in a violent crime.
More informationThe Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices
The Health and Benefit Trust Fund of the International Union of Operating Section 1: Purpose of This Notice Notice of Privacy Practices Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL
More informationWHAT HAPPENS IN A PERSONAL INJURY CASE
WHAT HAPPENS IN A PERSONAL INJURY CASE From Negotiating With Insurance Companies To Trial By Michael A. Schafer, Attorney at Law 440 South Seventh Street, Ste. 200 Louisville, Kentucky 40203 (502) 584-9511
More informationSELECT SERVICES FLAT FEE REPRESENTATION AGREEMENT page 1 of 8
Utah Family Law, LC Tel. No. 801-466-9277 E-mail: eric@divorceutah.com Attorney Eric K. Johnson - Attorney Russell W. Hartvigsen Mail: 2666 South 2000 East, Suite 101 Salt Lake City Utah 84109 REMEMBER:
More informationINJURY INFORMATION WORSHEET
APPENDIX A INJURY INFORMATION WORSHEET PATIENT INFORMATION Patient Name Contact Phone Today s DOB DOI HEALTH INSURANCE - PRIMARY Insurance Co. Name of Insured Benefits Phone# Insured SS# Insured DOB Policy
More informationRULE 4-1.5 FEES AND COSTS FOR LEGAL SERVICES
RULE 4-1.5 FEES AND COSTS FOR LEGAL SERVICES (a) Illegal, Prohibited, or Clearly Excessive Fees and Costs. [no change] (b) Factors to Be Considered in Determining Reasonable Fees and Costs. [no change]
More informationInsurance Producer Agreement
Insurance Producer Agreement Section 1 - Producer s Authority The Producer shall periodically submit risks to the Company for its consideration as authorized by the Company. These risks shall be located
More informationPERSONAL INJURY INTAKE SHEET
PERSONAL INJURY INTAKE SHEET PERSONAL INFORMATION Client's Name Aliases Date Phone H W SSN Race Sex Age DOB Marital Status M S D Resides With List addresses where client has resided during the past 10
More information2013 Nuts & Bolts Seminar Coralville
2013 Nuts & Bolts Seminar Coralville LITIGATION TRACK Work Comp 101 2:30 pm.-3:30 p.m. Presented by Tim Semelroth RSH Legal 425 Second Street SE, Suite 1140 Cedar Rapids, Iowa 52401 Phone: 319-365-9200
More informationINSTRUCTIONS FOR SETTLING A MINOR S CLAIM FOR PERSONAL INJURY
INSTRUCTIONS FOR SETTLING A MINOR S CLAIM FOR PERSONAL INJURY These instructions are intended as a guideline only and should not be relied upon as a comprehensive list of duties in a minor s settlement.
More informationPRACTICE GUIDELINES MEMORANDUM. RE: Sample Bankruptcy Motions and Orders for Personal Injury Practitioners and Trustees
PRACTICE GUIDELINES MEMORANDUM TO: FROM: Attorneys Practicing Before Me And Other Interested Persons C. Timothy Corcoran, III United States Bankruptcy Judge DATE: January 3, 2000 1 RE: Sample Bankruptcy
More informationAUTHORITY TO REPRESENT AND CONTINGENCY FEE AGREEMENT
AUTHORITY TO REPRESENT AND CONTINGENCY FEE AGREEMENT I, the undersigned client, do hereby retain and employ the Law Offices Of Zarakhovich&Associates, Inc., and, specifically, attorney Mariya Zarakhovich,
More informationPRESENTATION OF INJURY CLAIMS
PRESENTATION OF INJURY CLAIMS John D. Malanga MALANGA LAW FIRM 3116 West 5th Street Suite 212 Fort Worth, Texas 76107-2140 Telephone: 817-332-1776 Fax: 817-332-1722 Email: jmalanga@flash.net PRESENTATION
More informationThe A-B-C s of Motor Vehicle Collisions and Personal Injury Claims In Minnesota
The A-B-C s of Motor Vehicle Collisions and Personal Injury Claims In Minnesota Douglas E. Schmidt Accident Attorney 13911 Ridgedale Drive Suite 110 Minnetonka, MN 55305 952.473.4530 Fax: 952.544.1308
More informationTRONOX TORT CLAIMS TRUST. Individual Review and Arbitration Procedures for Category A and Category D Personal Injury Claims
TRONOX TORT CLAIMS TRUST Individual Review and Arbitration Procedures for Category A and Category D Personal Injury Claims Pursuant to Sections 3.4 and 3.5 of the Tronox Tort Claims Trust Distribution
More informationPRELIMINARY LIFE INSURANCE APPRAISAL REQUEST
PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST INSURED INFORMATION (If more than one insured, please duplicate this page and complete for each insured.) Name SSN Current Address Date of Birth Day Telephone
More informationCOOPER & TANIS, P.C.
COOPER & TANIS, P.C. Attorneys At Law Robert M. Cooper Leonard D. Tanis Cynthia Feldmiller, Paralegal Joyce M. Bergmann, Of Counsel Nova M. Frank Michael R. Taylor Dear Client: Thank you for selecting
More informationMaritime Injury Cases
Mailing Address: P.O. Box 34538 Seattle, WA 98124-1538 Maritime Injury Cases The following are the questions most frequently asked by our clients about Maritime injury cases. Obviously, the questions and
More informationComplete all pages of the application, especially the signature page.
Dear Applicant: Thank you for your interest in filing for Crime Victims Compensation benefits. Our goal is to assist victims of crime in accessing financial assistance to help them recover from the traumatic
More informationNEBRASKA PROPERTY AND LIABILITY INSURANCE GUARANTY ASSOCIATION ACT
NEBRASKA PROPERTY AND LIABILITY INSURANCE GUARANTY ASSOCIATION ACT Section. 44-2401. Purpose of sections. 44-2402. Kinds of insurance covered. 44-2403. Terms, defined. 44-2404. Nebraska Property and Liability
More informationGeorgia Board for Physician Workforce
Board for Physician Workforce Spotlight on National Tort Reform & Reform in the Surrounding States August 2010 Tort reform continues to be a highly debated issue at both the state and national level. In
More informationDear Participant, If you have any questions, please call the Customer Service Office at 702-733-9938. Sincerely, Culinary Health Fund
1901 Las Vegas Blvd. So. Suite 107 Las Vegas, Nevada 89104-1309 (702) 733-9938 www.culinaryhealthfund.org Dear Participant, We have been informed that you and/or your dependent(s) have been involved in
More informationPersonal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
More informationCONTRACT FOR LEGAL SERVICES
! Parties:! THIS AGREEMENT is made on the day of, 2012, in Plano, Collin, Texas, between ("Client"), and Reeves Law Firm, P.C. ("Attorney"):! In consideration of the mutual promises herein contained, the
More informationSPECIAL TOPICS IN GUARDIANSHIP COMPROMISING CLAIMS FOR MINORS AND INCAPACITATED ADULTS. November 8, 2013
SPECIAL TOPICS IN GUARDIANSHIP COMPROMISING CLAIMS FOR MINORS AND INCAPACITATED ADULTS November 8, 2013 Stephanie F. Brown McMickle, Kurey & Branch 200 South Main Street Alpharetta, GA 30009 (678) 824-7800
More informationCITY ADMINISTRATOR EMPLOYMENT AGREEMENT
CITY ADMINISTRATOR EMPLOYMENT AGREEMENT DATE: November 12, 2008 PARTIES: City of North Bend, Coos County, Oregon, an Oregon Municipal Corporation (City) [EMPLOYEE NAME] (Administrator) RECITAL: The purpose
More informationacknowledgment of health center privacy policy, privacy practices, and privacy procedures PATIENT PRIVACY
LAST NAME FIRST NAME OF BIRTH 001 acknowledgment of health center privacy policy, privacy practices, and privacy procedures PATIENT PRIVACY! HOPE s PRIVACY ACKNOWLEDGMENT PAGE 1 OF 1 HOPE s Statement of
More informationFAX FAX #: 817-850-9801. From: Phone: 817-850-9800. Company Name: Lincoln Factoring, LLC. Phone: Company Name: Fax: Number of Pages: Date
Date FAX FAX #: 817-850-9801 Phone: 817-850-9800 Company Name: Lincoln Factoring, LLC From: Phone: Company Name: Fax: Number of Pages: VERIFICATION FORM FUNERAL HOME CONTACT AMOUNT OF ASSIGNMENT NAME OF
More informationHow To Settle A Car Accident In The Uk
PERSONAL INJURY COMPENSATION CLAIM GUIDE PERSONAL INJURY COMPENSATION CLAIM GUIDE This booklet has been produced by D.J. Synnott Solicitors to give our clients an understanding of the personal injury compensation
More informationIN THE SUPERIOR COURT OF STATE OF GEORGIA. File No., Defendant. COMPLAINT FOR MODIFICATION OF CHILD SUPPORT
IN THE SUPERIOR COURT OF COUNTY STATE OF GEORGIA, Plaintiff, v. Civil Action File No., Defendant. COMPLAINT FOR MODIFICATION OF CHILD SUPPORT 1. Jurisdiction and Venue (Choose a, b, or c) a) The Defendant
More informationCIVIL LITIGATION ASSISTANCE SCHEME CONDITIONS OF ASSISTANCE
APPLICATION CIVIL LITIGATION ASSISTANCE SCHEME CONDITIONS OF ASSISTANCE 1. Applications for funding under the Civil Litigation Assistance Scheme can only be submitted through a private legal practitioner
More informationYour Personal Guide To Your Personal Injury Lawsuit
Your Personal Guide To Your Personal Injury Lawsuit Know How To Do Things Right When You ve Been Wronged You have questions. And most likely, you have a lot of them. The good news is that this is completely
More information