Your First Name

Your Last Name

Firm Name

Firm Type Corp General Partnership Individual Institutional Limited Company Limited Partnership LLC LLP LP Other PC PLC PLLC Professional Association Professional Limited Liability Partnership Sole Proprietorship

Address

Telephone (Numbers Only)

Cellular (Numbers Only)

Fax

Email

Case Name

Type of Case Personal Injury Adult - Sole Counsel Personal Injury Adult - Referring Counsel Personal Injury Adult - Co-Trial Counsel Personal Injury (WD/Infant/Incomp) - Sole Counsel Personal Injury (WD/Infant/Incomp) - Referring Counsel Personal Injury (WD/Infant/Incomp) - Co-Trial Counsel Worker's Comp Vouchers MDL or Mass Tort - Sole Counsel MDL or Mass Tort - Co-Trial Counsel MDL or Mass Tort - Referring Counsel Class Action

Date of Settlement or Award

Amount of Settlement or Award

Amount of Attorney Fee or Award

Are you sole counsel on this case? Yes No

Preliminary Court Approval Date

Final Court Approval Date

Company Name

Address

Adjustor Name

Email Address

Telephone Number (Numbers Only)

Claim Number

Claims Administrator

Settlement Website

Attorney Name

Name of Law Firm

Address

Telephone Number (Numbers Only)

Email Address

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