Client Information - Personal Injury

The information we are asking you to furnish is confidential and will not be given to anyone without your consent.

Save & Return

Although not required, we strongly recommend that you create an account. By creating an account you will be able to save your progress and make edits as any information changes throughout the duration of your case. (optional)

Client Information

First Name

Last Name

Date of Accident +

Street Address

Address Line 2

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Email Address

Date of birth: +

Are you married?

Yes

No

Spouse's Name

Street Address (if different than above)

City

State

Zip Code

Phone Number

Accident Information

Accident Location (street, county and state)

Did the at fault driver receive a citation? If so, what for?

Did you receive a citation? If so, what for?

Which sheriff's office or police department reported to the scene?

What was the officer's name who took the report?

Any witnesses? If so list any names, addresses and contact numbers you have

Explain IN DETAIL how the accident occurred (Were you driving? Where were you sitting? How did it happen? What type of impact was it? Etc...)

Pain and injuries you sustained due to THIS accident

Upload an image or scan of accident report

Vehicle Information

If your vehicle (or the vehicle you were in) has been taken to a shop, then what is name of shop?

Shop Street Address

City

State

Shop Phone Number

Shop's estimated cost of repairs

Employment Information

If you incurred lost wages please complete the section below.

Employer

Employer Street Address

Employer Address Line 2

Employer City

Employer State

Employer Zip Code

Monthly Gross Wages

Hourly

Salary

Hourly Rate

Average Hours Per Week

Prior Accidents and Injuries

Prior accident date (estimate if you don't know exact date) +

Injuries from accident

Doctors seen for that accident

Prior accident date (estimate if you don't know exact date) +

Injuries from accident

Doctors seen for that accident

Prior accident date (estimate if you don't know exact date) +

Injuries from accident

Doctors seen for that accident

Defendant's (at fault) Information

Defendant's Name

Phone Number

Street Address

City

State

Zip Code

Defendant's (at fault) Insurance

Defendant's Insurance Company

Adjuster's Name

Policy Number

Claim Number

Medical Treatment for This Accident

Were you transported via ambulance? If so, which ambulance company?

1. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

2. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

3. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

4. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

5. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

Future Medical Treatment

1. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

5. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone Number

City

State

Zip Code

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

Health Insurance

Check all that you have or that you can use because of a family member:

None

Medicaid

Medicare

Private/Group Private/Group

1. Insurance Company

Name of person on policy

Policy Holder

Group Number

Policy Number

Member Number

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

2. Insurance Company

Name of person on policy

Policy Holder

Group Number

Policy Number

Member Number

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

Your Car Insurance

Your Car Insurance Company

Policy Number

Claim Number

Insurance Adjuster's Phone Number

Insurance Adjuster's Name

If you are NOT the owner of the vehicle that was in the accident, and the owner of the vehicle has car insurance list that below. Insurance Company:

Car Insurance Company

Policy Number

Claim Number

Insurance Adjuster's Phone Number

Insurance Adjuster's Name

This is acknowledgement that submitting this form does not in any way bind this firm to represent you. Until this matter is accepted by a member of the firm, we will not be able to undertake any representation. *

I Agree