ATTORNEY/PARALEGAL QUESTIONNAIRE:

Attorney/Paralegal Name:

Attorney/Paralegal Email address:

Phone number:

Client information:

Name of Client/Case:

Nature of Accident:

Injuries Sustained:

Medical Specials:

Client Still Treating: Yes No

UIM1 Carrier:

Limits:

UIM2 Carrier:

Limits:

MedPay: Yes No Amount:

Health Insurance: Yes No

Is Health Insurance ERISA or subrogable: Yes No

Liability Carrier:

Liability Limits:

Has client received other pre-settlement advances? Yes No

Defendant accepted liability?: Yes No

Any offers of settlement?: Yes No Amount:

Pre-Existing Medical?: Yes No

Other comments or information which may be helpful in evaluating this case:

After submitting this form, please forward the following documentation by fax or email:

Scan/email the above listed documents to info@greatbaycapitalinc.com or fax to 843.342.6858.