PERSONAL INJURY

1

Your Name* This field is required.

Prefix

First Name

Middle Name

Last Name

Suffix

2

Cybersecurity, Technology, Security and Communications Consent* This field is required.In order to provide our clients with efficient and convenient legal services, our law office will communicate and transmit documents using e-mail, social media, cell phone, text messages, internet and web and fax. Because cybersecurity and technology as a whole continues to evolve, there may be risks communicating in these manners, including risks related to confidentiality and security and those associated with being hacked. By entering the information on this form, you are consenting to such e-mail, social media, cell phone, internet, zoom, web and fax communications. You are also acknowledging the risks and accepting them. In addition, our law office uses Drop-box and other cloud based technologies and services with servers located in facilities outside of our office. Most of our electronic data, emails, and documents are stored in this manner. By entering the information on this form, you understand and consent to having communications and documents pertinent to your Matter stored and handled in this cloud based manner. Because technology continues to evolve, there are risks, as already discussed above. By filling out your name and initialling the box below, you knowingly, intelligently consent to everything in this paragraph.

First Name

Middle Name

Last Name

3

Novel Corona Virus (Covid-19) Safety Precautions and Notice* This field is required.As you probably know, Covid-19 is officially a pandemic. It is similar to the flu in that it causes fever and similar flu-like symptoms. It primarily impacts older people over the age of 60 and those who have underlying health issues such as diabetes and respiratory illnesses as well as obesity. If you have a health condition, it would be prudent to stay away from crowded places and clean your hands often. Interestingly, children, young and healthy people are not usually seriously impacted. If young healthy people contract Covid-19, they generally get symptoms for 2 weeks and get better. Like most things in life, there are of course some exceptions. In light of the spread of this disease, our office will respond by exercising appropriate due care and caution. First, we are continuing to be vigilant about washing our hands and keeping our office clean. Second, as we often need to meet with clients, we will need to ask you some personal questions to determine the best way to mitigate risk for both your health and ours. We would ask that you also vigilantly wash your hands and if necessary, cough into your elbow (not your hands). When we finally do meet, we will not be shaking hands or making body contact of any kind. These are just simple but important precautions. Now that we have that out of the way, we would appreciate it if you would please answer the 3 questions below. Please note that we will still be glad to service you, even if you answer yes to any one or more of the questions below. We will simply find a way to work with you remotely if necessary or some alternative method of dealing with your legal issues. Thank you for your cooperation and understanding during these interesting times.

Have you traveled in the past 3 months?

Have you been to an event in 3 months?

Have you been ill in the past 3 months?

4

How did you get referred to our law office?* This field is required.Please give name and contact info of the person / attorney or website and contact info.

Name of the referring party or website

Contact info.

5

Phone Number* This field is required.

Area Code

Phone Number

6

Email* This field is required.

example@example.com

7

Your birth date* This field is required.

Date

8

Your marital status* This field is required.Necessary for settlement purposes

9

Your home address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

10

Name, address, and phone of your employer

11

Were you in the course and scope of your job when the injury occurred?

12

Where did the incident occur?* This field is required.Address, cross streets, or other approximate location identifier

13

Approximate date of the incident* This field is required.

Date

14

Approximate time of incident

Hour

Minutes

15

Name and contact info of witnesses, if any

16

What type of personal injury?* This field is required.Mark all that apply

Battery between two individuals / fist fight / bar fight

Slip and fall / premise liability

Sexual assault

Medical Malpractice

Wrongful Death

Worker's compensation / job related

Burn

Other

17

How many injured people in your group?* This field is required.

Just myself

Me and another person

Me and two others

Three or more

18

The contact info of the party and/or business who caused you harm* This field is required.Name, address, manager name and contact, etc.

20

Your and other party's Insurance infoBusiness Insurance, Personal Insurance, Umbrella Insurance, etc.

22

Describe the incident and timeline of events* This field is required.What, when, where, how, why

23

Where were you coming from right before the incident?

Home

Work

School

Other

24

Where were you going at the time of the incident?

Home

Work

School

Other

25

How often do you drink?* This field is required.

Almost every day

A couple of times per week

A couple of times per month

I don't drink

26

Did you have something to drink within 24 hours of the incident?* This field is required.

Yes, the same day

Yes, the night before

No

Other

27

Have you ever been cited for a DUI?* This field is required.Must check as many as apply

Yes, the same day

Yes, the night before

Less than 1 year ago

Over 1 year ago but less than 2 years

Over 2 years ago

1 DUI within 5 years

Over 1 DUI

No, never

Other

28

Upload all photos and documents you have associated with your accident.Driver's license, insurance cards, medical ins cards, Medi-Cal/Medicare, car damage, injuries, etc.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

29

Have you talked to another lawyer about this case?* This field is required.

Yes, I have a lawyer now

Yes, but the lawyer didn't take my case

Yes, but didn't want to hire him/her/them

No

Other

30

When was the last time you hired a lawyer?* This field is required.Mark all that apply

Less than 6 months ago

Over 6 months under 1 year

Over 1 year less than 2 years

Over 2 years under 5 years

Never

Other

Worker's compensation related

Personal Injury / Car Accident related

Divorce

32

What is your preferred method of communication?* This field is required.Everyone should fill out

Email daily

Email nights / weekends

Text / IM daily

Text / IM nights / weekends

Phone daily

Phone nights / weekends

Other preference

33

What is your preferred spoken and written language?* This field is required.Everyone should fill out

English fluent

English is a second langauge

Spanish fluent

Korean fluent

Other

34

How soon after the incident did you seek medical attention?

Same day ER / ambulance

Next day

Within 5 days

I have not seen a doctor

Within 30 days

I have an appointment

35

Would you like a video conference / consultation?By clicking "Yes", you consent to and accept the risks involved with Zoom meetings, including those related to privacy. You must be in a private and quiet area without anybody else in the room during the meeting.

Yes

No

36

Within the next 7 days, pick 3 dates and times when you can come to our office for a 1 hour consultation or when you are available for a phone or zoom call. We will answer your questions and go over the entire process at that time.

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