Civil/ Personal Injury Intake Form

Civil/Personal Injury Intake Form

IMPORTANT: You must complete the form as required and click SUBMIT at the bottom of the page for it to be sent.

* Indicates required field

Potential Client's Name *

First

Last

Age *

Your Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Accident/Incident Information

Health Insurance Information

At the time of the Accident/Incident were you covered by any Health Insurance programs? (Check all that apply) *

Provide the Insurance Providers Name, Claims Address, ID# and Name of Primary Insurance Holder *

Who provides the insurance? *

Employer Spouses Employer Other

If employer provided insurance, please provide the following:

Employer Name Providing the Insurance *

Approximate Number of Employees *

If you filed any insurance claims provide the name of the facility providing care, dates care was received, approximate bill amount, and the name of the insurance provider you filed the claim with. *

Automobile Accident Information

Name of Police Agency completing the accident report *

List any citations issued by police. Include who received the ticket and the violation if known. Also, include court dates. *

Was there an insurance policy covering the vehicle you were driving or riding in? *

Yes No Unknown - not my vehicle

Have you filed a claim with the vehicle insurance company? *

Yes No Unsure

Provide the name of your vehicle insurance company, policy number, adjuster name, claim number and date filed if applicable. *

Facts of the case

Please provide a brief narrative as to the day of your accident/incident. Where had you been just prior to and where were you going? Were there any passengers in your vehicle? What was the weather like that particular day? Were there any witnesses? What circumstances were there surrounding your accident/incident? *

How can we help? And if we were completely successful, what would that success look like to you? *

History of Claims Information

Have you ever filed a lawsuit before? *

Yes No

If you have filed a lawsuit before, briefly describe the circumstances, include dates *

If you are here because of an injury, have you ever had an injury similar to the one that you now claim exists? Please describe the injury, approximate dates, or enter "Not Applicable" if you have not *

Bankruptcy

Have you ever filed bankruptcy in any state? *

Yes No

Please describe and include the approximate dates, city and state *

Employment Information

Were you employed and working at the time of Accident/Injury? *

Yes No Not employed

If you were working enter the name of your employer. If self-employed enter the nature of your business. *

Job Title *

Rate of Pay *

Supervisor Name *

How many days of work have you missed as a result of injuries from the Accident/Incident? *

Did you lose income as a result of the work missed as a result of injuries from the Accident/Incident (Enter "none" if no wages lost) *

If you found us through referral, please provide the name of the person that referred you *

Submitting this form is for intake review purposes only and does not constitute an attorney client relationship.

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