In order to best serve you, and know if you’re a good fit for submitting a claim, Regal Consulting Group needs to collect the following information. Your accurate and thorough answers are needed to properly pre-screen your eligibility. Rest assured your information is strictly confidential and safe with us.

Note: this questionnaire is expected to take 20 minutes to complete. Be sure to hit “SUBMIT FORM” at the bottom of the form or we will not receive your information.