Case Request Form

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{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

Have you worked with us before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requester Information

Law Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requester Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requester Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requester Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Law Firm Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Request {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you know the insurance carrier for the case you are submitting today? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Due to an overwhelming demand for our Policy Existence service, we are accepting these requests on a case by case basis only. Once your Policy Existence request is submitted to us, we will assess the case to determine viability and if we are able to accept the request for processing, your case will be assigned to a researcher immediately.

If we are unable to accept your request at this time, the $150 deposit paid upon submission of the request will be refunded. You will be welcome to resubmit the case for processing once this service is made available again for every case request.

This is the only instance in which the deposit will be refunded. Under any other circumstances, the $150 deposit is non-refundable.

If you would like to recieve further communication from Pacific Liability Research regarding when this service will be available for every case, please let us know by clicking here.

We are very sorry for any inconvenience.

Are you redeeming any prepaid cases today? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter the purchase code given to you upon confirmation of your prepaid bundle: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue, convert=Cognito.maskText }

Purchase code entered {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Case Submissions

Case {binding ItemNumber}

Order Information

Plaintiff's Name/Case Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Loss {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

*Pricing increases depending on time from date of loss, see Pricing for specifics.

Within 1 Year / 1-3 Years / 3-5 Years

Do you know the insurance carrier for this case? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of Case {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of Policy Existence {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Personal Auto Processing Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Homeowner's Processing Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Commercial Processing Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Umbrella Processing Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy Existence Processing Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Information Requested {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Defendant Information

Defendant Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Defendant Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Defendant Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Defendant Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Driver's License {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Vehicle {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

VIN Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is Defendant information the same as Policyholder information? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policyholder Information

Name on Policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policyholder Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policyholder Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policyholder Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Information

Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

*Specialty Carriers incur an additional $30 fee. These include:

AAA, Farmers Group, Mercury, State Farm

Claim Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adjuster {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adjuster Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is this case currently in litigation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the date this case was filed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the county this case was filed in? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Supporting Documents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Additional Notes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Referred By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which Account Representative has assisted you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Representative's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Associate Attorney's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which Trial Lawyers Association were you referred by? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Trial Lawyers Association {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which social media platform? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which partnering law firm? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which search engine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Word of mouth referral source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other referral source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Case Request Form

Requester Information

Case Submissions

Case {binding ItemNumber}

Order Information

Defendant Information

Policyholder Information

Insurance Information

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Case Request Form

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Your progress has been saved.

Case Request Form

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Requester Information

Case Submissions

Case {binding ItemNumber}

Order Information

Defendant Information

Policyholder Information

Insurance Information