Attorney Questionnaire Paralegal/Attorney Name: Paralegal/Attorney Email Law Firm and Phone number: Client's Name: Amount of Special Damages: Liability Insurance Limits: UM/UIM Insurance Limits: Does Client have Health Insurance Unknown Yes Yes, but it's ERISA/Subrogable No Any settlement offer and amount: Are there or do you anticipate any other Liens against this file? ERISA/Subrogation Lien? Medicare/Medicaid Lien? Child Support Lien? Other Advances? Any other Liens? Pre-existing Medical Condition? Any other comment/information regarding this case? After you submit the information, please send us the following: 1. Copy of the Accident Report; 2. Summary of Special Damages; 3. Pertinent Medical Records; 4. Any other information useful in evaluating this case. Please Scan/Email the requested information to info@greatbaycapital.com or you may fax it to (843) 724-6480.
