New Case Application & Conflict Check – Living

Please fill out all four (4) pages and then click the submit button. A copy of the application will automatically be emailed to you. We will respond within one (1) business day. Thank you for your interest.

Step 1 of 4

Contact Information
Today's Date*
Month
Day
Year
Your Name*
First Last
Email*
Enter Email Confirm Email
Bar No.
Your Agency*
Your Title*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax

Case & Stakeholder Information
Case Name*
Case Number*
Jurisdiction*
County*
City, State*
Plaintiff*
Attorney Representing Plaintiff*
Defendant*
Attorney representing Defendant*
Law Enforcement Agency (optional)
Charges / Indictment(s)*
Trial Dates / Hearing Dates*

Core Investigation Data
Name of Patient*
First Last
Sex*
- Female
- Male
Biological sex of Patient
Date of Injury*
Month
Day
Year
Date of Birth*
Month
Day
Year
Primary Hospital Providing Care*
Most Responsible Physician*
Major Diagnoses*

Brief Summary of Official Circumstances of Injury/Injuries
Brief Summary of Official Circumstances of Injury/Injuries*
Additional Information (optional)
Funding Source(s)
Check all that apply:*
- Government sources
- Private sources
- Other
If "other" funding sources, please specify:
CAPTCHA