Do you have a legal claim in the state of Texas? Are you looking for an easy-to-use form that can help navigate your case and document any information related to your claim? If so, our law firm is here to provide assistance! Today we will be discussing how utilizing a Texas Legal Claim Form can maximize efficiency when submitting a legal claim in the Lone Star State. We’ll take an in-depth look at what these forms offer and why they are essential to understanding the rules regarding filing claims in Texas courts.
Question | Answer |
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Form Name | Texas Legal Claim Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | Qty, AUTHORIZATING, affirming, 1972 |
PART 1 PARTICIPANT INFORMATION
Member Name:
Subscriber ID:
Group ID:
Mailing Address:
Mailing City, ST, Zip: |
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Email Address: |
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Home/Cell Phone No.: |
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Office Phone No.: |
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PART 2 CLIENT INFORMATION (if not listed above)
Name:
Date of Birth:
Relationship to Member:
Contact Phone No.:
By checking this box I certify that the client/dependent (excepting spouse of Member) was under the age of 25 at the time when the legal matter occurred.
CLAIM FORM
PART 3 COVERAGE VERIFICATION
Contact TLPP for eligibility verification prior to providing service(s)
Toll (800)
Date:
Authorization No.:
Notes:
OBTAINING VERIFICATION IS NOT A GUARANTEE OF PAYMENT
PART 4 ATTORNEY INFORMATION
Attorney Name:
Attorney TLPP ID:
Billing Address
Billing City, ST, Zip: ,
Email Address:
Telephone No.:
Fax No.:
Updated contact information provided
PART 5 SERVICES PERFORMED (refer to TLPP Participating Attorney Fee Schedule for codes and descriptions)
First Date of Service
Final Date of Service
Code
Description
Qty/Hour(s)
Charge
TOTALS
PART 6 COURT RELATED INFORMATION
Court/Administrative/Charge Date:
First Filing Date:
Court/Agency Name:
Cause/Docket No.:
PART 8 CLAIM SUBMISSION
Fax (512)
Mailing 7500 Rialto Blvd, Bldg One, Ste 120, Austin, Texas 78735
NOTICE By submitting this claim you are affirming that the legal matter has been finalized. Be advised that TLPP does not make interim payments.
PART 7 AUTHORIZATING SIGNATURES
MEMBER OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any legal or other information necessary to process this claim. I also request payment of benefits either to myself or to the party who accepts TLPP.
Participating Member Signature |
Date |
I certify that the service(s) listed were necessary for the legal services of the client and were personally furnished by me or my employee(s) under my personal direction. I certify that the foregoing information is true, accurate and complete. The itemized statement submitted includes hourly billing. I agree not to bill the Member and/or the Client for any covered legal services.
Participating Attorney Signature |
Date |
PART 9 TLPP Office Use Only
Effective Date: |
Process Date: |
Received Date: |
Payment: |
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Coverage Type: |
Batch No.: |
Claim Count: |
Claim No.: |
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Toll (800) |
Web www.tlpp.org |
CREATED AND ENDORSED BY THE STATE BAR OF TEXAS SINCE 1972 |
12/2011 |