PERSONAL INJURY (AUTO ACCIDENT)

Member / Your Name* This field is required.

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First Name

Middle Name

Last Name

Suffix

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 putting your initials below, you knowingly, intelligently consent to everything in this paragraph.

First Name

Middle Name

Last Name

Member's ID:Legal plan members only

Please select how you were referred to our firm / Legal planPlease choose one

MetLife

ARAG

Yelp

Google

Former client

Another attorney

Other

Case Assist No./Eiligibility No.:Legal plan members only

Last 4 of your SSN:Legal plan members only

Phone Number* This field is required.

Area Code

Phone Number

Email* This field is required.

example@example.com

Your date of birth* This field is required.

Date

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

Spouse's NameIf Married

Prefix

First Name

Middle Name

Last Name

Suffix

Your home address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Name, address, and phone of your employer/company you work* This field is required.Address, cross streets, or other approximate location identifier

Were you in the course and scope of your job at the time of injury?Helps determine damages and other liability

What is your job title/duties/and annual salary?Helps determine damages and other liability

How many days of the week do you work from home?Helps determine damages and other liability and helps us find local medical treatment for you

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

Approximate date of the incident* This field is required.

Date

Approximate time of incident

Hour

Minutes

Name and contact info of witnesses, if any

Is / was anybody involved a government employee?* This field is required.Mark all that apply

Yes, Federal employee

Yes, State employee

Yes, local city or county employee

Yes, other

Other

I don't know

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

Two car rear end injury accident

Multi-car rear end injury accident

Intersection / T-bone car injury accident

Motorcycle or bike injury accident

Commercial / work truck / semi-truck related accident

Uber / Lyft involved accident

Possible DUI

Wrongful Death

Worker's compensation / job related

Other

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

Just myself

Me and another person

Me and two others

Three or more

Where there any children and/or car seats in the car at the time of the accident? If so, how many carseats and ages of children?* This field is required.The car you were in

V#1 Your car (name, make, model and year)* This field is required.The car you were in

V#2 At-Fault party's car (name, make, model and year)The other guy

V#3 for multi-car accident (name, make, model and year)Skip if only 2 cars involved

Police report?* This field is required.

Yes, local police

Yes, OC Sherrif

Yes, LA Sherrif

No Police report

Other

V#1 Your Car Insurance info* This field is required.Insurance company, policy#, claim# (if any), Policy info, etc. auto and umbrella policy

V#2 At-fault party's car Insurance infoInsurance company, policy#, claim#, contact info, insurance info, vehicle info

V#3 Insurance infoIf this accident involved more than 2 vehicles, please provide the additional information

Describe your other property damage (such as car seats, sunglasses, etc.)Please discuss any other personal property that was damaged from this accident

What injuries did you sustain from this accident?* This field is required.Mark all that apply

What injuries or medical conditions did you already have prior to this accident?* This field is required.Mark all that apply

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

Where were you coming from right before the incident?* This field is required.

Home

Work

School

Other

Where were you going at the time of the incident?* This field is required.

Home

Work

School

Other

What were the road conditions?* This field is required.Skip if not car accident otherwise select all that apply

Rush hour commuter traffic

Freeway accident / pile up

Rain / bad weather / night

Clear sunny day and dry road

Intersection accident

Wet or messy floor / ground

light traffic / not crowded

Other

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

Seldom on special occassions

Other

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

Yes, the same day

Yes, the night before

Other

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 or more DUI within 5 years

No, never

Other

How soon after the accident did you seek medical attention?* This field is required.

Same day ER / ambulance

Next day

Within 5 days

I have not seen a doctor

I have an appointment

Within 30 days

After 30 days

Other

Upload all photos and documents you have associated with your accident. ie: Car damage, road conditions, injuries, bruises and scratches, driver's licenses, car insurance cards, medical insurance card, Medicare/Medi-Cal card, ER/doctor's notes, etc.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

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

Other

When was the last time you were in an accident?* This field is required.

Less than 6 months prior to this

Between 6 months to 1 year ago

Over 1 year under 2 years

Over 2 years less than 5 years

Over 5 years ago

Never

Other

Is your car driveable?* This field is required.Skip if not car accident

Yes, I'm driving it

Yes, but barely

No, it's at a body shop

No, I need a body shop

No, it's a total loss

Maybe but I need help

Which health insurance do you have?* This field is required.Everyone should fill out

Anthem Blue Cross / Blue Shield

Work Provided HMO

Work provided PPO

Kaiser

Medicare

Individual Plan

Medi-cal

Other

No Health insurance

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

Email daily

Text / IM daily

Text / IM nights / weekends

Phone daily

Phone and Email nights / weekends

Other preference

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

Are you interested in a zoom meeting/consultation?* This field is required.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

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

Please let us know if you have any plans to move, change jobs, or go on vacation in the next 12 months? Please give us details. It is important that we be able to contact you and that we are aware of any major changes that might impact your case.

We are a busy office and each client is unique and equally important to us. Although we welcome your calls and emails anytime, it is usually best to schedule a time specifically dedicated to your needs so that we can both be focused on the issues most important to you. Also, if for some reason we are not able to return your call or email within 2 days, please follow up. Thank you for taking the time to fill out this form. It goes a long way in helping get things started.

PERSONAL INJURY (AUTO ACCIDENT)