Please print this out, fill in the blanks, and fax to 813-226-3128

Type of Insurance		Insurance Details
Health:	____	Insurance Company:	_______________________
Auto:	____	Dates of Coverage:	_______________________
UM:	____	Years Policy in Effect:	_______________________
Life:	____	Policy Limits:	_______________________
Diability:	____	State of Purchase:	_______________________
		Policy Bought By:	Employer	___	You?	___
Med Mal?	____	Type of Policy/Own PCC:	_______________________
		Amount of Premium:	_______________________
		Benefit Amount:	_______________________
		Benefits began-ended	_______________________

Date of Disability:	____	Occupation when Disabled:	______________
Date of Injury:	____	Occupation when Injured:	______________
Describe Disability/Injury/Treatment Concerns:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Your Treating Doctor(s):  _____________________________________________
Did Insurance Company send you to an 'Independent Medical Expert'? ____
To whom and when? __________________________________________
*Please provide all IME Reports
What medical records do you have? _____________________________________
Currently working in an occupation outside your field? _______________________

Employer(s)	(Last	5 years):	Name/Address
___/___/___	to	present	________________________________________
			________________________________________
___/___/___	to	___/___/___	________________________________________
			________________________________________
___/___/___	to	___/___/___	________________________________________
			________________________________________
Referred by:  _______________________________________________________
Consulted another attorney?____________________________________________