Pennsylvania personal injury lien request 2026

1. Click ‘Get Form’ to open the Pennsylvania Personal Injury Lien Request in the editor.
2. Begin by filling out the CLIENT INFORMATION section. Enter your last name, first name, CIS/MA ID number, middle initial, Social Security Number, and date of birth in the specified format.
3. Select the TYPE OF INCIDENT by checking one of the options provided. If 'Other' is selected, briefly explain the incident. Additionally, list any body parts that were injured and indicate whether treatment has been completed.
4. Provide the DATE OF INCIDENT/INJURY in the required format and select any applicable incident type from the options listed.
5. In the CLIENT’S ATTORNEY INFORMATION section, enter details about your attorney including their law firm name, mailing address, city, state, telephone number, and fax number.
6. Fill out both PARTY INSURANCE INFORMATION sections with details about insurance companies involved. Include company names, adjuster names, mailing addresses, policyholder information, and claim numbers as necessary.
7. Finally, complete the form by entering your information in the 'Completed by' section and providing a date before submitting it via fax to the designated number.

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