PERSONAL INJURY INTAKE FORM

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—CONFIDENTIAL—

DEAR CLIENT, YOU HAVE MADE A WISE DECISION TO ASSIGN YOUR CASE TO OUR LAW FIRM. ALL

THE INFORMATION YOU PROVIDE HERE IS VITAL TO ASSESS YOUR CASE AND HELPFUL TO CLAIM FOR

MAXIMUM COMPENSATION. PLEASE PRINT THIS WORKSHEET AND PROVIDE THE INFORMATION

BELOW. IF YOU DO NOT KNOW THE ANSWER TO A QUESTION LEAVE IT BLANK.

DATE: ATTORNEY NAME: CASE FILE NO:

CLIENT INFORMATION

1. PERSONAL INFORMATION

NAME: ___________________________________________________________________________

ADDRESS:__________________________________________________________________________

__________________________________________________________________________________

________________________________________________________________________________

HOME PHONE: _____________________ WORK PHONE: ____________________ __________

FAX NUMBER: _____________________ E-MAIL: ___________________________________

DATE OF BIRTH:____________________ SOCIAL SEC. NO.: ___________________________

NATIONALITY: _____________________ CELL PHONE: _______________________________

BEST TIME TO CONTACT: _____________________________________________________________

ARE YOU AN EXISTING CLIENT? YES [ ] NO [ ]

HOW DID YOU HEAR ABOUT US: GOOGLE [ ] CLIENT REFERRAL [ ] ATTORNEY REFERRAL [ ]

NAME OF THE CLIENT OR ATTORNEY WHO REFEERRED YOU:_______________________________

PREFERRED LANGUAGE: ENGLISH [ ] SPANISH [ ]

MARITAL STATUS: SINGLE [ ] MARRIED [ ] DIVORCED [ ]

IF MARRIED PROVIDE AN INFORMTION AS BELOW

SPOUSE NAME: ___________________________________________________________________

ADDRESS: ________________________________________________________________________

_________________________________________________________________________________

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HOME PHONE: _____________________ WORK PHONE: ____________________ _________

FAX NUMBER: _____________________ E-MAIL: ___________________________________

DATE OF BIRTH:____________________ SOCIAL SEC. NO.: ___________________________

NATIONALITY: _____________________ CELL PHONE: _______________________________

OCCUPATION _____________________________________________________________________

SPOUSEC EMPLOYER AND ADDRESS_____________________________________________________

_________________________________________________________________________________

CHILDREN NAME, AGE AND EDUCATION:

1. __________________________________________

2. __________________________________________

OTHER DEPENDENTS NAME, AGE, RELATIONSHIP, AND LOCATION:

1. ______________________________________________________________________________

2. ______________________________________________________________________________

3. ______________________________________________________________________________

2. INFORMATION ON THE CLIENT EDUCATION

EDUCATION: ____________________________________________________________________

YEAR OF COMPLETION: ____________________________________________________________

3. INFORMATION ON THE CLIENT EMPLOYMENT

EMPLOYEE [ ] SELF EMPLOED [ ] OWNS A BUSINESS [ ] UNEMPLOYED [ ]

NAME OF EMPLOYER:________________________________________________________________

POSITION:________________________________________________________________________

HOW LONG YOU WERE EMPLOYED WITH THIS EMPLOYER?______________________________ ___

MONTLY INCOME:___________________________________________________________________

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EMPLOYMENT ADDRESS:_____________________________________________________________

_________________________________________________________________________________

TELEPHONE:__________________________________ FAX NO.:____________________________

SUPERVISOR NAME AND TELEPHONE NO.:_______________________________________________

DATES OF WORK MISSED:_____________________________________________________________

TOTAL LOST WAGES: _______________________________________________________________

4. INFORMATION ON BUSINESS:

DO YOU OWN A BUSINESS? YES [ ] NO [ ]

BUSINESS NAME :___________________________________________________________________

BUSINESS LOCATION:________________________________________________________________

_________________________________________________________________________________

MONTHLY BUSINESS INCOME: ________________________________________________________

5. INFORMATION ON ANY OTHER ATTORNEYS YOU HAVE CONTACTED REGARDING THIS MATTER:

ATTORNEY NAME AND LOCATION:________________________________________________

CONTACT DATE: _________________________________________________________________

6. INFORMATION ON MILITARY SERVICE:

HAVE YOU BEEN IN THE MILITARY SERVICE? YES [ ] NO [ ]

IF SO,ANSWER THE QUESTIONS BELOW:

SERVICE NUMBER:__________________________________________________________________

TYPE OF DISCHARGE:________________________________________________________________

DATES OF SERVICE:__________________________________________________________________

INFORMATION ON ANY SERVICE CONNECTED INJURIES OR DISABILITY IF ANY:___________________

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__________________________________________________________________________________

PERCENTAGE OF DISABILITY:___________________________________________________________

PRESENT CONDITION OF SERVICE CONNECTED INJURY OR DISABILITY: _________________________

__________________________________________________________________________________

DO YOU RECEIVE PAYMENTS FOR SERVICE CONNECTED INJURIES? YES [ ] NO [ ]

IF SO, DETAILS______________________________________________________________________

7. INFORMATION ON PRIOR CLAIMS AND LAW SUITS

DO YOU HAVE ANY PRIOR CLAIMS OR LAW SUITS ? YES [ ] NO [ ]

IF SO, ANSWER THE QUESTIONS BELOW

DATE: ____________________ NATURE OF CLAIM: ____________________

YOUR OPPONENT DETAILS: __________________________________________________________

RESULT: ___________________________________________________________________________

6. PRIOR POLICE RECORD

DO YOU HAVE ANY PRIOR CRIMINAL BACKGROUND? YES [ ] NO [ ]

IF SO, ANSWER THE QUESTIONS BELOW

PROVIDE DETAILS ON THE DATE, PLACE, COURT NAME, TYPE OF CHARGE AND OUTCOME: ________

__________________________________________________________________________________

8. PRIOR DISABILITY CLAIMS

DID YOU HAVE ANY DISABILITY CLAIMS? YES [ ] NO [ ]

IF SO, ANSWER THE QUESTIONS BELOW

INFORMATION ON THE WORKERS COMPENSATION CLAIM:_________________________________

DATE OF INJURY:___________________________________________________________________

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DETAILS ON PAYMENTS IF ANY:________________________________________________________

__________________________________________________________________________________

INFORMATION ON ANY OTHER DISABILITY PAYMENTS:_____________________________________

__________________________________________________________________________________

9. PRIOR PHYSICAL EXAMINATIONS

DID YOU HAVE PHYSICAL EXAMINATION FOR ANY PURPOSE DURING THE LAST FIVE YEAR? YES [ ]

NO [ ]

IF SO, ANSWER THE QUESTIONS BELOW

DATE:_______________________________ PLACE________________________________________

NAME OFDOCTOR __________________________________________________________________

PURPOSE_________________________________________________________________________

( employment, promotion, insurance, selective service, armed forces, etc)

10. PRIOR ACCIDENT AND INJURIES

DID YOU HAVE ANY PRIOR ACCIDENTS OR INJURIES ? YES [ ] NO [ ]

IF SO, PROVIDE INFORMATION ON THE DATE, PLACE, NATURE OF THE ACCIDENT ________________

__________________________________________________________________________________

__________________________________________________________________________________

11. ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE

HAVE YOU EVER BEEN TREATED FOR ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE? YES [

] NO [ ]

IF SO, PROVIDE THE DETAILS:__________________________________________________________

__________________________________________________________________________________

12. PRIOR ILLNESS OR DISEASE

DID YOU HAVE ANY PRIOR ILLNESS OR DISEASE? YES [ ] NO [ ]

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IF SO, PROVIDE THE DETAILS

DATE___________________ NATURE OF ILLNESS:_________________________________________

DURATION:________________ TREATED BY:____________________________________________

NAME AND ADDRESS OF THE HOSPITAL:_________________________________________________

__________________________________________________________________________________

13. TROUBLE WITH EYES OR EARS

DO YOU NOW, OR HAVE YOU EVER HAD TROUBLE WITH EYES OR EARS: YES [ ] NO [ ]

IF SO, PROVIDE THE DETAILS

__________________________________________________________________________________

__________________________________________________________________________________

14. RADIOACTIVE SUBSTANCES AND ASBESTOS

HAVE YOU EVER WORKED WITH RADIOACTIVE SUBSTANCES OR ANY OTHER SUSTANCE ALLEGED TO

CAUSE ANY DISEASES? YES [ ] NO [ ]

15. INFORMATION ON HEALTH INSURANCE DENIAL

HAVE YOU EVER BEEN DENIED OF HEALTH INSURANCE? YES [ ] NO [ ]

IF SO, BY WHICH COMPANY AND REASON FOR DENIAL:_____________________________________

_________________________________________________________________________________

16. INFORMATION ON ACCIDENT

DATE OF ACCIDENT: _________________________________________________________________

LOCATION OF ACCIDENT:____________________________________________________________

NAMES OF OTHER PEOPLE INVOLVED IN THE ACCIDENT/INJURY, THEIR ADDRESS AND TELEPHONE

NUMBER:

1. ___________________________________________________________________________

__________________________________________________________________________

2. __________________________________________________________________________

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__________________________________________________________________________

3. __________________________________________________________________________

__________________________________________________________________________

4. ___________________________________________________________________________

__________________________________________________________________________

HAVE YOU MISSED ANY TIME FROM WORK AS A RESULT OF YOUR INJURY? YES [ ] NO [ ]

IF SO, LIST THE DATES YOU WERE UNABLE TO WORK:

FROM: ___________________ TO: ____________________________

FROM: ___________________ TO: _____________________________

17. LIST OF WITNESSES

1. NAME: ______________________________________________________________________

ADDRESS: ______________________________________________________________________

TELEPHONE NO: ____________________________________________________________________

RELATIONSHIP: _____________________________________________________________________

2. NAME: ______________________________________________________________________

ADDRESS: ______________________________________________________________________

TELEPHONE NO: ____________________________________________________________________

RELATIONSHIP: _____________________________________________________________________

3. NAME: ______________________________________________________________________

ADDRESS: ______________________________________________________________________

TELEPHONE NO: ____________________________________________________________________

RELATIONSHIP: _____________________________________________________________________

18. INFORMATION ON THE INJURY

STATE ALL INJURIES KNOWN TO BE A RESULT OF THE ACCIDENT: ___________________________

_________________________________________________________________________________

_________________________________________________________________________________

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LENGTH OF TIME CONFINED TO BED: ________________________________________________ ___

LENGTH OF TIME CONFINED TO HOUSE: ________________________________________________

STATE PRESENT CONDITIONSINCLUDING SCARS, DISABILITIES, DEFORMATIES, DISCOMFORTS, ETC.,

DUE TO THE INJURIES: _____________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________________

19. INFORMATION ON THE TREATMENTS

LIST ALL PHYSICIANS, NURSES, THERAPISTS, CHIROPRACTORS, SURGEONS, OR OTHER HEALTH

CAREPROFESSIONALS YOU HAVE SEEN FOR YOUR INJURIES

1. NAME/ TITLE____________________________________________________________________

ADDRESS__________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

TELEPHONE NUMER:_______________________________________________________________

DATES OF VISIT OR ADMISSION:_______________________________________________________

NATURE OF CARE____________________________________________________________________

__________________________________________________________________________________

DATE OF DISCHARGE: ______________________________________________________________

2. NAME/ TITLE____________________________________________________________________

ADDRESS_________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________

TELEPHONE NUMER:_______________________________________________________________

DATES OF VISIT OR ADMISSION:______________________________________________________

NATURE OF CARE__________________________________________________________________

__________________________________________________________________________________

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DATE OF DISCHARGE: _______________________________________________________________

3. NAME/ TITLE____________________________________________________________________

ADDRESS__________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________________

TELEPHONE NUMER:_______________________________________________________________

DATES OF VISIT OR ADMISSION:______________________________________________________

NATURE OF CARE__________________________________________________________________

________________________________________________________________________________

DATE OF DISCHARGE:________________________________________________________________

20. INFORMATION ON SETTLEMENT OFFERS:

HAVE YOU RECEIVED ANY SETTLEMENT OFFERS FOR THIS INJURY? YES [ ] NO [ ]

IF SO, PROVIDE THE INFORMATION BELOW

DATE OF SETTLEMENT OFFER: _______________________________________________________

AMOUNT OF THE SETTLEMENT OFFER: $________________________________________________

NAME, ADDRESS AND TELEPHONE NUMBER OF THE COMPANY OR THE PERSON WHO OFFERED YOU

THE SETTLEMENT:_________________________________________________________________

_________________________________________________________________________________

__________________________________________________________________________________

21. INFORMATION ON THE DRIVER LICENSE

DRIVER’S LICENSE:_______________________________________________________________

DRIVER’S REGISTRATION:___________________________________________________ ______

CAR MODEL AND TYPE: ____________________________________________________ ______

INSURANCE COMPANY: ___________________________________________________________

ADJUSTER AND TELEPHONE NO.:_______________________________________________

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CLAIM/POLICY NO.:_______________________________________________________________

22. INFORMATION ON HEALTH INSURANCE:

__________________________________________________________________________

__________________________________________________________________________

23. CLIENT’S INSURANCE INFORMATION

DOES CLIENT OR ANYONE IN CLIENT’S HOUSE HAVE AUTO INSURANCE? YES [ ] NO [ ]

IF YES, STATE NAME AND ADDRESS OF INSURANCE OWNER:_________________________________

_______________________________________________________________________________

_______________________________________________________________________________

INSURANCE OWNER’S LICENSE: _______________________________________________________

INSURANCE OWNER’S CAR REGISTRATION: ____________________________________________

INSURANCE COMPANY: _____________________________________________________________

ADJUSTER AND TELEPHONE NO.:_____________________________________________________

CLAIM/POLICY NO.: _______________________________________________________________

24. DEFENDANT AND INSURANCE COVERAGE INFORMATION (VEHICLE WHICH STRUCK CLIENT)

NAME: _________________________________________________________________________

ADDRESS:________________________________________________________________________

__________________________________________________________________________________

TELEPHONE NO.: __________________________________________________________________

DEFENDAT’S LICENSE: ______________________________________________________________

DEFENDANT’S VEHICLE REGISTRATION: _________________________________________________

VEHICLE MODEL AND TYPE: __________________________________________________________

INSURANCE COMPANY NAME AND ADDRESS:_____________________________________________

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________________________________________________________________________________

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ADJUSTER NAME ADDRESS AND TELEPHONE NO.: ________________________________________

________________________________________________________________________________

________________________________________________________________________________

CLAIM/POLICY NO.: _______________________________________________________________

DEFENDANT ATTORNEY NAME ADDRESS, AND TELEPHONE NUMBER:__________________________

__________________________________________________________________________________

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25. FACTS OF CASE

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FOR OFFICE USE ONLY:

ATTORNEY NOTES AND CHRONOLOGY OF EVENTS:

ATTORNEY NOTES

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CHRONOLOGY OF EVENTS

DATES EVENT

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