Intake Questionnaire | Personal Injury laywer

Personal Injury Intake Questionnaire

In order to effectively represent your legal interests, we need honest, accurate, and complete answers to the questions listed below. Please carefully respond to the best of your ability. The failure to do so may severely compromise your claim and/or result in this firm’s immediate withdrawal.

Client Identification

Full Legal Name:

Street Address

Telephone

Alternate Telephone:

City, State and Zipcode

Driver’s License Number

VIN Number of your vehicle

Email Address:

Date of Birth:

Social Security Number:

Marital Status:

Spouse’s Full Name:

Spouse’s Telephone:

Health Insurance Information:

Company Name:

Policy Number:

Employment History

Occupation/Job Title:

Job Decripon

Professional Licenses / Certifications:

Current Employer Information:

Name:

Address

Telephone Number:

Immediate Supervisor’s Contact Information:

Name:

Address

Telephone Number:

Compensation:

Annual Salary (If applicable)

Hourly Rate (If applicable)

Other Compensation (If applicable)

Typical Weekly Schedule (e.g.: Mon 9-5):

Total Amount of Work Missed as a Result of This Incident

Your Automobile Insurance Coverage

Name of Insurance Carrier:

Policy Number:

Agent Information:

Name:

Address

Telephone Number:

Email Address:

Please obtain a copy of your insurance policy declaration page along with any riders and bring with you to your consultation.

At-Fault Party’s Insurance Coverage

Name of Carrier:

Policy Number:

Insurance Adjuster Information:

Name:

Telephone Number:

Address

Email Address:

Incident Facts:

Accident Date:

Accident Time:

Accident Location:

(E.g.: City, County, State, Street/Cross-street)

Provide a Detailed Description of Incident:

If not, why not?

If Yes, to whom?

Citation No.

Hearing Date and Location

Police Report / Case Number:

How did you leave the scene of the incident?

If Yes, whom? and describe his/her injuries, if known:

List All Vehicle Occupants (List Driver First if Not You):

1. Occupant

2. Occupant

3. Occupant

List All Other Witnesses:

1. Witness:

2. Witness:

3. Witness:

Property Damage:

Describe damage to your vehicle:

Describe damage to other vehicles involved:

Name, Address and Telephone Number of Mechanic:

Bodily Injuries

Describe nature of your bodily injuries:

On a Scale of 1-10, please state the level of your pain:

If So, Please Explain:

How have your injuries changed your lifestyle? BE SPECIFIC- THIS INFORMATION IS VITAL!!

a) Generally:

b) Sexual Activities:

c) Social/Recreational Activities

d) Job-Related Activities:

e) Household-Related Activities:

Please Provide Information Regarding Doctors and/or Facilities That Have Treated You Since This Incident:

Name

Address

Telephone:

Other Helpful Information

If Yes, Please Explain the Circumstances:

How did you hear about C. Kelly Law, LLC.?

By signing below, you represent that the information provided by you in this document is accurate and true to the best of your knowledge

Name

Date

Authorized Signature

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Personal Injury Intake Questionnaire

Client Identification

Health Insurance Information:

Employment History

Current Employer Information:

Immediate Supervisor’s Contact Information:

Compensation:

Typical Weekly Schedule (e.g.: Mon 9-5):

Your Automobile Insurance Coverage

Agent Information:

Please obtain a copy of your insurance policy declaration page along with any riders and bring with you to your consultation.

At-Fault Party’s Insurance Coverage

Insurance Adjuster Information:

Incident Facts:

(E.g.: City, County, State, Street/Cross-street)

List All Vehicle Occupants (List Driver First if Not You):

List All Other Witnesses:

Property Damage:

Bodily Injuries

How have your injuries changed your lifestyle? BE SPECIFIC- THIS INFORMATION IS VITAL!!

Please Provide Information Regarding Doctors and/or Facilities That Have Treated You Since This Incident:

Other Helpful Information

By signing below, you represent that the information provided by you in this document is accurate and true to the best of your knowledge

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