CLIENT INTAKE FORM

CLIENT INTAKE FORM

Auto Accident
DATE OF ACCIDENT:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
REFERRED BY:
PLAINTIFF’S INFORMATION
FULL NAME:
DOB:
GENDER:
S.S.#:
IF UNDER 18, LEGAL GUARDIAN:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:(home)
(work)
(cell)
E-MAIL:
example@example.com
MARITAL STATUS:
SPOUSE’S NAME:
EMERGENCY CONTACT (RELATIVE/FRIEND)
NAME:
PHONE:
ACCIDENT INFORMATION (Get copy of exchange/police report)
EXACT LOCATION OF ACCIDENT:
CITY/COUNTY:
DETAILS OF HOW ACCIDENT HAPPENED:
WERE YOU CITED FOR ACCIDENT?
IF SO, FOR WHAT?
PASSENGERS:
SEATBELT USED?
REPORT MADE?
POLICE DEPT.:
POLICE REPORT CASE #:
HAVE YOU GIVEN ANY STATEMENTS?
TO WHOM?
POTENTIAL WITNESSES:
POTENTIAL WITNESSES:
WERE PHOTOGRAPHS TAKEN? (PLEASE PROVIDE PHOTOGRAPHS)
PROPERTY DAMAGE
TOTAL PD/ESTIMATE:
TOTAL PD/ESTIMATE:
WHO PAID FOR THE DAMAGES?
IS CLIENT HANDLING PD?
VEHICLE DAMAGES:
WHERE IS THE VEHICLE LOCATED:
DO YOU NEED A RENTAL?
DO YOU HAVE COLLISION INSURANCE?
DEFENDANT’S INFORMATION
DRIVER'S NAME:

First NameLast Name
AGE:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE #:
PASSENGERS:
TYPE OF VEHICLE:
LICENSE PLATE:
OWNER OF VEHICLE:
WERE THEY CITED?
FOR WHAT?
DEFENDANT’S INSURANCE INFORMATION
COMPANY:
POLICY #:
CLIENT’S AUTO INS. CO.:
POLICY #:
CLAIM #:
UM?
ANY OTHER VEHICLES REGISTERED IN YOUR HOUSEHOLD:
CLIENT’S HEALTH INSURANCE INFORMATION (Upload copy of card)
CLIENT’S HEALTH INS. CO.:
POLICY #:
MEDICARE/MEDICAID?
OTHER MEDICAL COVERAGE?
INJURIES/TREATMENT
CLIENT’S INJURIES (BE SPECIFIC):
CLIENT’S INJURIES (BE SPECIFIC):
DOCTOR:
PHONE #:
CITY/STATE:
DATE OF FIRST TREATMENT:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DID YOU GO TO THE ER? :
HOSPITAL NAME:
DATE OF HOSPITAL VISIT?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
LENGTH OF STAY?
ADDITIONAL DOCTORS SEEN:
ADDITIONAL DOCTORS SEEN:
PRIOR MEDICAL HISTORY
PRIOR NECK INJURIES OF ANY KIND (year and description):
PRIOR BACK INJURIES OF ANY KIND (year and description):
ANY OTHER PRIOR INJURIES OF ANY KIND (year and description):
PREVIOUS ACCIDENT, WORK COMP CLAIM OR SLIP & FALLS?
ACCIDENT TYPE:
DATES:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PREVIOUS LAW SUIT?
EMPLOYMENT
MAKING LOST WAGE CLAIM?
LOST TIME FROM WORK?
DATES LOST FROM WORK IF APPLICABLE
ANYTHING ADDITIONAL YOU NEED TO ADD?
Upload The Following Documents
UPLOAD REQUIRED DOCUMENTS

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By signing below I am certifying that all above information is true and correct.
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CLIENT INTAKE FORM

PLAINTIFF’S INFORMATION

EMERGENCY CONTACT (RELATIVE/FRIEND)

PROPERTY DAMAGE

DEFENDANT’S INFORMATION

DEFENDANT’S INSURANCE INFORMATION

INJURIES/TREATMENT

PRIOR MEDICAL HISTORY

EMPLOYMENT