Reasonable and Necessary Declaration

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    Company Name*
    First and Last Name*
    Email*
    Phone Number*
    Attorney Name (If you are not the Attorney)
    Claim Number
    Case Caption
    Claimant Name*
    Claimant DOB
    Treating Providers
    Records Volume
    Defense Attorney
    Declaration Due to Client
    Explanation of Declaration
    Potential Trial Date(s)
    Potential Trial Locations