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Submit & Insure a Claim Personalized Search The National List of Attorneys’ Account Representatives are standing by to help you locate the best possible Attorney Member for your Claim. If you wish to use this complimentary service, please complete the form below or call us at 800.227.1675.

An Account Representative will contact you with recommendations within one business day.


*Name:
*Company:
*Phone:	Ext:
*Fax:
*Email:

Please complete either the Local Counsel or the Statewide Coverage section

*To Request Local Counsel* *(handle one or more claims in a specific venue):*

Your File Number:

Defendant (Debtor or Adverse Party):

Defendant's City:

Defendant's State or Province:

Country:

Amount of Claim:

*To Request Attorney Statewide Coverage* *(handle multiple claims in venues throughout a state):*

State or Province:

Approximate Number of Claims:

Average Balance of Claims:

Contingency Fee:

Type of Claims:	Commercial
	Retail
	Subrogation
	Bankruptcy
	Insurance Defense
	Transportation
	Other

Rates:	Contingency Amount
	Hourly
	Flat Fee
	Other

Please provide any additional information that can assist us in finding you an attorney that meets your requirements.
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