Name: Sweeney Merrigan Personal Injury Lawyers
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Decedent Name (First)
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What is your relationship to the decedent?

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Please describe any conscious pain that the decedent suffered as a result of the injuries caused by the defendant:
Generally, in your own words, how did this incident occur?
Who was the decedent’s primary care physician at the time of the events?
Please describe the decedent’s educational and professional history:
Please state any conversations and/or communications you are aware of with the defendants:
Are there any writings or notes or journal entries about the incident? If so, please explain:
Was the decedent Medicare eligible? Please answer "Yes" or "No":
What health insurance did the decedent have?
Did the decedent suffer monetary losses, lost wages, or lost benefits as a result of this incident? Please explain:

Please upload any Medical Records relating to the incident above.
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Please upload any Medical Records relating to the incident above.
Please upload the decedent's Autopsy Report above.
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Please upload the decedent’s Autopsy Report above.
Please upload the decedent's Death Certificate above.
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Please upload the decedent’s Death Certificate above.
Please upload the decedent's Will and/or any Estate Planning Documents above.
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Please upload the decedent’s Will and/or any Estate Planning Documents above.
Please upload your Letter of Appointment as executor, administrator, or personal representative of the decedent’s estate above.
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Please upload your Letter of Appointment as executor, administrator, or personal representative of the decedent’s estate above.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
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Please upload any Medical Bills or Hospital Bills resulting from the incident above.
Please upload any Photographs or Videos relating to the incident above.
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Please upload any Photographs or Videos relating to the incident above.
Please upload any and all Investigative and/or Incident and/or Accident Reports above.
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Please upload any and all Investigative and/or Incident and/or Accident Reports above.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
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Max. file size: 512 MB.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
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Medical Malpractice Onboarding Form – Representative

Meet the Personal Injury Attorneys at Sweeney Merrigan Law, LLP