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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

Health Insurance Information:

Employment History

Current Employer Information:
Immediate Supervisor’s Contact Information:
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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