a:9:{s:6:"active";b:1;s:7:"subject";s:54:"Manley & Associates "Liability Intake" Form Submission";s:6:"sender";s:47:"[your-name] <wordpress@manleyandassociates.com>";s:9:"recipient";s:120:"lawatson@bmanleymsa.com, nformisano@bmanleymsa.com, msareferrals@manleyandassociates.com, atimms@manleyandassociates.com";s:4:"body";s:2860:"From: [your-name] <[your-email]>

FORM TYPE: Liability Intake

<h3 class="heading3">YOUR INFORMATION</h3>

YOUR NAME:
[your-name]

YOUR FIRM:
[your-firm]

YOUR ADDRESS:
[your-address]

YOUR CITY:
[your-city]

YOUR STATE:
[your-state]

YOUR ZIP:
[your-zip]

YOUR EMAIL:
[your-email]

YOUR PHONE:
[your-phone]

YOUR FAX:
[your-fax]

I AM THE:
[Iamthe]


<h3 class="heading3">PLAINTIFF</h3>

PLAINTIFF NAME:
[plaintiff-name]

GENDER:
[gender]

CLAIM FILE NUMBER:
[plaintiff-file]

PLAINTIFF ADDRESS:
[plaintiff-add]

PLAINTIFF CITY:
[plaintiff-city]

PLAINTIFF STATE:
[plaintiff-state]

PLAINTIFF ZIP:
[plaintiff-zip]

DATE OF BIRTH:
[d-ob]

PLAINTIFF PHONE NUMBER:
[plaintiff-phone]

DATE OF INJURY
[date-in]

STATE OF JURISDICTION
[state-oj]

DATE OF MEDICARE ELIGIBILITY:
[date-medi]

SSDI Beneficiary:
[SSDIBeneficiary]

DATE OF MEDICATION (IF SET):
[date-medication]

SETTLEMENT AGREEMENT: $
[settlement-agreement]

Underlying worker's compensation claims are involved.:
[underlaying]

I1: Please list body parts and/or medical conditions to be included in the MSA. :
[list-body]

I2: Please list body parts and/or medical conditions that are NOT to be included in the MSA. :
[list-body2]

Brief description of injury (example: slipped and fell, rear-ended in auto accident, etc.):
[list-body3]

Guardian Appointed:
[GuardianAppointed]

Other comments:
[Othercomments]


<h3 class="heading3">PLAINTIFF ATTORNEY</h3>

PLAINTIFF ATTORNEY NAME:
[pa-name]

PLAINTIFF ATTORNEY FIRM:
[pa-firm]

PLAINTIFF ATTORNEY ADDRESS:
[pa-add]

PLAINTIFF ATTORNEY CITY:
[pa-city]

PLAINTIFF ATTORNEY STATE:
[pa-satate]

PLAINTIFF ATTORNEY ZIP:
[pa-zip]

PLAINTIFF ATTORNEY EMAIL:
[pa-email]

PLAINTIFF ATTORNEY PHONE:
[pa-phone]

PLAINTIFF ATTORNEY FAX:
[pa-fax]


<h3 class="heading3">ADJUSTOR</h3>

ADJUSTOR NAME:
[adjustor-name]

ADJUSTOR FIRM:
[adjustor-firm]

ADJUSTOR ADDRESS:
[adjustor-add]

ADJUSTOR CITY:
[adjustor-city]

ADJUSTOR STATE:
[adjustor-state]

ADJUSTOR ZIP:
[adjustor-zip]

ADJUSTOR EMAIL:
[adjustor-email]

ADJUSTOR PHONE:
[adjustor-phone]

ADJUSTOR FAX:
[adjustor-fax]


<h3 class="heading3">DEFENSE ATTORNEY</h3>
DEFENSE ATTORNEY NAME:
[deffenseattorney-name]

DEFENSE ATTORNEY FIRM:
[deffenseattorney-firm]

DEFENSE ATTORNEY ADDRESS:
[deffenseattorney-address]

DEFENSE ATTORNEY CITY:
[deffenseattorney-city]

DEFENSE ATTORNEY STATE:
[deffenseattorney-state]

DEFENSE ATTORNEY ZIP:
[deffenseattorney-zip]

DEFENSE ATTORNEY EMAIL:
[deffenseattorney-email]

DEFENSE ATTORNEY PHONE:
[deffenseattorney-phone]

DEFENSE ATTORNEY FAX:
[deffenseattorney-fax]


<h3 class="heading3">AVAILABLE SERVICES</h3>

[checkbox-496]
[checkbox-497]
[checkbox-498]
[checkbox-499]
[checkbox-500]
[checkbox-501]
[checkbox-502]
[checkbox-503]
[checkbox-504]
[checkbox-506]

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