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  Benefits Questionnaire
 
To apply for the Accident Care Plan, please complete the following questionnaire.
   
  Your name and contact information
First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip
Phone (Home) (Cell) (Other)
____________________________________________________________________________________________
 
Accident Date (mm/dd/yyyy)

 
Are you interested in
Additional Healthcare Cash advance from your future settlement Both

 
Did the injury result from a car, truck or motorcycle accident?
YES NO
If NO, please explain:


 
Were you a pedestrian,passenger,or driver?
Passenger Pedestrian Driver Other

 
Were you at fault for the accident?
YES NO

 
Were the police or emergency services called to the scene of the accident?
YES NO

 
Did you seek treatment at an emergency room or doctor’s office within 7 days of the accident?
YES NO

 
Do you have any insurance? Please check all that apply:
Auto Health Medicare Medicaid Medpay Other
____________________________________________________________________________________________
 
Are you currently represented by an attorney?
YES NO DON’T KNOW

If Yes, Please provide your attorney information.
Attorney Name Attorney Phone

Please enter the promotion code from the letter you received.
PROMO CODE


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