Litigation Intake Questionnaire - Malloy & Malloy, P.L.

PRIVILEGED AND CONFIDENTIAL - WORK PRODUCT

ATTORNEY-CLIENT COMMUNICATION / ATTORNEY WORK PRODUCT

Please complete all sections below.

Client Name:

Please insert and/or confirm the name of the Entity/Individual being represented in this matter.

MM Ref No:(Required)

Our reference number is usually listed as "MM Ref.:" in the Subject line of our emails, but you may respond "N/A" if not known.

Attorney Contact:(Required)

Choose the Primary Attorney who is assisting you with this matter.

PRIMARY CONTACT PERSON(S)

Who will be the primary contact person(s) for this litigation? The contact person(s) will need to be accessible to the firm to aid in the handling of your case, to provide instructions upon request, and to assist us with requests for information/documents for the case.

Name:(Required)

First Last

Email:(Required)

Telephone:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Primary Contact(s)

Are there any additional individuals that should be designated a primary contact.

Second Primary Contact Name:

First Last

Email:

Telephone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Primary Contacts

Please list Name, Email, Telephone and Address of any Additional Primary Contacts

BILLING CONTACT PERSON(S)

Who will be the contact person(s) for billing? Billing statements will be transmitted by email.

Same as Primary Contact(s)

Yes

No

Billing Contact Name:

First Last

Billing Contact Email:

Billing Contact Telephone:

Billing Contact Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Billing Contacts (if applicable):

Please provide the name, email and telephone number of any additional billing contacts that should receive billing statements.

CORPORATE DISCLOSURE STATEMENT

Are there any parent corporations or publicly held corporations that own 10% or more of your company’s stock?

Yes

No

Please provide the names of the parent corporation(s) or publicly held corporation(s):

INSURANCE INFORMATION (DEFENDANT CASES ONLY)

You are advised to evaluate all insurance policies for possible coverage and duties of disclosure. For example, some Commercial General Liability policies provide coverage for intellectual property claims under “advertising injury” provisions.

Policies

Please identify any relevant insurance policies below and upload copies of the policies and declaration pages.

Please upload copies of the policies and declaration pages:

Drop files here or

Max. file size: 256 MB.

Name of person completing this questionnaire:(Required)

First Last

Email:(Required)

Enter Email Confirm Email

Phone:

Date Completed:(Required)

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Litigation Questionnaire

PRIVILEGED AND CONFIDENTIAL - WORK PRODUCT

ATTORNEY-CLIENT COMMUNICATION / ATTORNEY WORK PRODUCT

PRIMARY CONTACT PERSON(S)

BILLING CONTACT PERSON(S)

CORPORATE DISCLOSURE STATEMENT

INSURANCE INFORMATION (DEFENDANT CASES ONLY)

Miami:

Boca Raton:

Jacksonville:

Orlando:

Tampa:

Request Initial Consultation at No Charge

Litigation Questionnaire

***PRIVILEGED AND CONFIDENTIAL - WORK PRODUCT***

***ATTORNEY-CLIENT COMMUNICATION / ATTORNEY WORK PRODUCT***

PRIMARY CONTACT PERSON(S)

BILLING CONTACT PERSON(S)

CORPORATE DISCLOSURE STATEMENT

INSURANCE INFORMATION (DEFENDANT CASES ONLY)

Request Bank Details

Request Initial Consultation at No Charge

PRIVILEGED AND CONFIDENTIAL - WORK PRODUCT

ATTORNEY-CLIENT COMMUNICATION / ATTORNEY WORK PRODUCT