Pre-Litigation Forms

You are only required to fill out the fields highlighted in yellow in the forms below.

Automatic Forms Start

Your Name*
First Last
Address*
Phone Number*
Email*
If you do not have an email, please use "me@rosenbauminjuryfirm.com"
Your Paralegal*
Hidden
Current Date*
MM slash DD slash YYYY
Hidden
One Year Date
DD slash MM slash YYYY

MSPRC

Hidden
Name
First Last
Hidden
Email
Hidden
Paralegal

Oops! We could not locate your form.

HIPAA

Hidden
Name
First Last
Hidden
Patient Name
First Last
Hidden
Email
Hidden
Address
Hidden
Paralegal
Hidden
Date
MM slash DD slash YYYY
Hidden
Future Date
MM slash DD slash YYYY

Verification to Interrogatories

Hidden
Name
First Last
Hidden
Patient Name
First Last
Hidden
Email
Hidden
Address
Hidden
Paralegal
Hidden
Date
MM slash DD slash YYYY
Hidden
Future Date
MM slash DD slash YYYY

WAGE LOSS INSTRUCTIONS
If you have missed any time from work due to the injuries that you have sustained (i.e. non-paid/paid, PTO, sick days, etc.), please kindly have your employer complete the “Wage & Salary Verification form” and have your treating physician complete the “Attending Physicians Report.” We will need both forms completed in order to include any lost wages as a part of your claim.

1. Wage and Salary Verification
2. Attending Physician’s Report

Please provide us these forms after you complete them by submitting below.

Treatment Status

Hidden
Name
First Last
Hidden
Patient Name
First Last
Hidden
Email
Hidden
Address
Hidden
Paralegal
Hidden
Date
MM slash DD slash YYYY
Hidden
Future Date
MM slash DD slash YYYY

Practice Areas