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Please provide as much information
as you can so that PILCO is better able to provide you the most
accurate evaluation possible.
PILCO will respond to you within
24 hours.
Required Fields are indicated by
an asterisk (*) |
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Mr.
Mrs.
Ms |
| Name * |
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| Address |
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| City * |
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| Postal Code |
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| Phone * |
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| E-mail Address * |
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| Age |
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| How did you hear about PILCO? |
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| Names of Parties Involved: |
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| When did your injury occur? |
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| How was the injury caused?
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| What are your injuries? |
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| Have you returned to
work? |
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Yes
No |
| If so, when? |
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| Where are you employed? |
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| What is your annual
income? |
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| What are your ongoing
problems? |
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| Have you applied for
accident benefits (through your own auto insurer) or for other
benefits (short term or long term disability benefits)? |
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| What accident benefits
have you received to date? What other benefits have you received
to date? |
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| Is there a shortfall
between your income and benefits paid? |
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| Who is
your insurance company? |
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| Do you
know the name of the insurance company of any other party involved
in your accident? |
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| Please
list expenses you have incurred as a result of your injuries |
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| Provide a list of the
names, addresses and telephone numbers of all hospitals, doctors,
etc., who have treated you as a result of this incident. |
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| Do you have a police
report or a report from a Collission Reporting Centre? |
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Yes
No |
| Please provide us with
any other information you feel PILCO needs to know at this time
to assist with your evaluation. |
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