Internal Office – Brogdon Law Firm | Pure Conceptions Multimedia

Letter of Representation (LOR) - Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Which type of LOR is this?*

Sending to Plaintiff's Insurance

Sending to 3rd Party's Insurance

Client name*

Date of Accident*

Name of insurance company*

Fax Number*

Insurance adjuster's name

Insurance adjuster's address

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance adjuster's phone number*

Claim number/Policy number*

Insured Name

Letter of Protection (LOP) - Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Patient name*

Provider's Company/Firm

Provider's Email

Contact Name

Provider's Address

Provider's Phone

Provider's Fax

Date of Loss*

Date of Birth*

Med Request Template - Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Client name*

Date of Accident*

Date of Birth*

Name of insurance company*

Insurance company address

Street Address Address Line 2 City State ZIP Code

Insurance company's email*

PIP File Request - Brogdon Law firm

"*" indicates required fields

Hidden

Date

Client name*

Date of loss*

Name of insurance company*

Insurance adjuster's name*

Insurance adjuster's address

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance adjuster's phone number*

Claim number*

PIP Demand - Brogdon Law firm

"*" indicates required fields

Hidden

Date

Client name*

Date of loss*

Name of insurance company*

Insurance adjuster's name*

Insurance adjuster's address*

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance Company Facsimile*

Claim number*

list of Medical Bills*

Facility Name

Date

Amount Owe

Total

PI Demand - Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Client name*

Date of loss*

Name of insurance company*

Insurance adjuster's name*

Insurance adjuster's address*

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance Company Facsimile*

Claim number*

File number*

Special Damage*

General Damage*

Grand Total

injuries sustained

This sentence will read: sustained injuries to his/her shoulder, neck, and back specifically the cervical, thoracic, and lumbar regions. All you need to type is the part of the sentence that lists the injuries, and is bold in the line.

Property Damage File Request - Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Client name*

Date of loss*

Name of insurance company*

Insurance adjuster's name*

Insurance adjuster's address

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance adjuster's phone number*

Claim number*

UM/UIM Demand -Brogdon Law Firm

"*" indicates required fields

Hidden

Date

Client name*

Date of loss*

Name of insurance company*

Insurance adjuster's name*

Insurance adjuster's address*

Street Address Address Line 2 City State ZIP Code

Insurance adjuster's email*

Insurance Company Facsimile*

Claim number*

File number*

list of Medical Bills*

Facility Name

Date

Amount Owe

Total Medical Expenses

General Damages

Total Damages