Case Evaluation | Blue Hill Capital

I

Applicant Information

Full Name of Plaintiff(s) *

Date of Birth *

Phone Number *

Email Address

Social Security Number (Last 4 Digits) *

State of Residence *

Any Passengers? *

Yes No

If Yes, How Many?

II

Attorney & Law Firm Information

Law Firm Name *

Attorney's Name *

Phone Number *

Email Address

Contingency Fee Agreement Signed?

Yes No

Percentage Fee Charged

III

Case Details

Type of Case (Check All That Apply) *

If Other, Please Describe

Date of Incident *

Time of Incident *

Location of Incident *

Plaintiff Vehicle Year, Make & Model *

Has PD Settled? *

Yes No

Who Paid?

How Much Was Paid?

Brief Description of Incident *

Police / Incident Report Filed?

Yes No

If Yes, Copy or Details

Liability Admitted or Disputed?

Admitted Disputed Unknown

Video / Photo Evidence Supporting Liability?

Yes No

IV

Injuries & Medical Treatment

Describe All Injuries Sustained *

Did Applicant Go to Hospital / ER?

Yes No

Date of First Treatment

Current Treatment Status *

Ongoing Completed

All Known Medical Providers & Facilities Visited

Surgery Performed or Recommended?

Yes No

If Yes, Please Describe

Total Medical Bills to Date

Any Medical Liens?

Yes No

If Yes, Total Lien Amount

V

Insurance & Liability

Name of Adverse Party *

Adverse Party Insurance Carrier

Policy Limits (if known)

Claim Number

Adjuster Name and Contact (if known)

Demand Sent?

Yes No

If Yes, Date

Offer Made?

Yes No

Amount Offered

VI

Damages & Recovery

Plaintiff Missed Work Due to Injuries?

Yes No

Estimated Wage Loss to Date

Future Wage Loss or Disability Claims?

Yes No

If Yes, Explain

Currently Receiving Public Benefits (SSI, SSDI, etc.)?

Yes No

Comparative Negligence or Causation Issues?

Yes No

If Yes, Explain

Estimated Case Value by Attorney (Gross)

VII

Prior Funding & Case History

Plaintiff Received Prior Legal Funding? *

Yes No

If Yes, Amount Funded

Funding Company Name

Buyout Amount (if known)

Prior Accidents / Injuries to Same Body Parts?

Yes No

If Yes, Please Describe

Plaintiff Filed for Bankruptcy?

Yes No

If Yes, Details and Current Status

VIII

Requested Funding Amount

Amount Plaintiff Is Seeking in Funding *

IX

Plaintiff Insurance Information

Plaintiff Had Auto Insurance at Time of Incident? *

Yes No

If Yes, Carrier Name

Policy Number

Claim Number (if applicable)

Claim Submitted to Plaintiff's Own Carrier?

Yes No

If Yes, Describe Type

Med-Pay Collision UM/UIM Other

UM/UIM Coverage?

Yes No Unknown

Is This a UM or UIM Claim?

Yes No

UM/UIM Policy Limits (Per Person)

UM/UIM Policy Limits (Per Occurrence)

If UM/UIM Claim, Provide Claim Status and Any Offers

Proof of Loss Submitted to Insurer?

Yes No

Coverage Issues or Delays from Plaintiff's Insurer?

Yes No

If Yes, Please Explain

X

Attorney Signature (Optional but Recommended)

"I affirm that to the best of my knowledge, the information provided above is accurate and this case is actively being handled on a contingency basis."

Attorney Printed Name (as signature)

Date

Case Evaluation Questionnaire

Applicant Information

Attorney & Law Firm Information

Case Details

Injuries & Medical Treatment

Insurance & Liability

Damages & Recovery

Prior Funding & Case History

Requested Funding Amount

Plaintiff Insurance Information

Attorney Signature (Optional but Recommended)