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Slip + Fall

Confidential Intake Form
Plaintiff

Information Regarding Plaintiff¹

Information Regarding Plaintiff’s Counsel

Information Regarding Opposing Side

Did they agree to participate in InstaResolve?

Information Regarding The Accident²

Was there and incident report?
Did owner have prior notice of condition that caused the fall?

Information Regarding Injuries

Did these injuries resolve?

Information Regarding Medical Treatment³

Information Regarding Medical Bills

Lien?
Lien?
Lien?
Lien?
Lien?

Information Regarding Lost Earnings

Is there a lost earnings claim?

If yes, what is the amount of lost earnings claimed?

Information About Impact on Life Activities

Plaintiff’s Settlement Demands

CCP 998?
CCP 998?
CCP 998?
CCP 998?

Settlement Offers

CCP 998?
CCP 998?
CCP 998?
CCP 998?

Other Information

Upload Documents
Upload Images
Upload Videos

Thanks for submitting!

1. Please fill out separate intake sheets for each Plaintiff.

2. If desired, upload Brief with additional information, photo(s)/video(s).

3. Upload medical records/reports if desired.

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