Client Intake Form (Motor-Vehicle Accident)
This Intake Form will facilitate our ability to represent you by providing the basic facts and information that pertain to your situation. Please complete the Intake Form as soon as possible, making sure to separately also forward all documents, letters, records, bills, photographs, and all other items related to your claim. These materials will assist our understanding of your matter.
Your Name
*
First Name
Middle Name
Last Name
Gender
Mobile Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Driver's License
Social Security Number
Family Information
Are You Married?
*
Yes
No
Spouse's Name
Spouse's Date of Birth
Spouse's Phone Number
Spouse's Email
Back
Next
Do You Have Children?
Yes
No
1st Child's Name
1st Child's Date of Birth
2nd Child's Name
2nd Child's Date of Birth
3rd Child's Name
3rd Child's Date of Birth
4th Child's Name
4th Child's Date of Birth
Emergency Contact
Emergency Contact (First and Last Name)
*
Emergency Contact's Relationship to You
*
Emergency Contact's Phone Number
*
The Accident
Date of Incident
*
-
Month
-
Day
Year
Location of Accident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
General Description of What Happened
*
Weather Conditions?
*
Location (Nearest Cross Streets, Street Address, or Landmark)
*
Back
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Police Report
*
Yes
No
Name of Police Department
Police Department Phone
Report Number
Other Incident Report(s)
Yes
No
Custodian of Incident Report(s)
Custodian Phone
Report Number
Your Vehicle Information
Year/Make/Model of Your Car (ex: 2020 Honda Civic)
Driver
Driver's Phone
Driver's Address
Passenger #1
Passenger #1's Phone
Passenger #1's Address
Passenger #2
Passenger #2's Phone
Passenger #2's Address
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Passenger #3
Passenger #3's Phone
Passenger #3's Address
Describe Damage to Your Car
*
Photographs of Property Damage
*
Yes
No
Repair Estimate
*
Yes
No
Cost of Repair
Vehicle is Totaled (Total Loss)
*
Yes
No
Not Sure
Your Vehicle Insurance
Name of Insurance Company
*
Claim Number
Name of Claims Adjuster
Phone
Medical Payment Coverage
Yes
No
Amount of MedPay Coverage
Uninsured/Underinsured Motorist Coverage
Yes
No
UM/UIM Coverage Limits
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Other Vehicle #1
Year/Make/Model of Other Car (ex: 2020 Honda Civic)
Describe Damage to Other Car
Photographs of Property Damage
Yes
No
Vehicle is Totaled
Yes
No
Not Sure
Other Vehicle #1 Insurance
Name of Defendant
*
Name of Insurance Company
Policy Number
Claim Number
Name of Claims Adjuster
3rd Party Adjuster Address
Phone
3rd Party Property Adjuster Fax
3rd Party Adjuster Email
Other Vehicle #2
Year/Make/Model of Car (ex: 2020 Honda Civic)
Describe Damage to Other Car
Photographs of Property Damage
Yes
No
Vehicle is Totaled
Yes
No
Not Sure
Back
Next
Other Vehicle #2 Insurance
Name of Defendant
Name of Insurance Company
Policy Number
Claim Number
Name of Claim Adjuster
Adjuster's Address
Phone
Fax
Email
Witness #1
Name
Phone
Address
Email
Witness #2
Name
Phone
Address
Email
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Witness #3
Name
Phone
Address
Email
Medical Treatment Providers
Have You Received Medical Treatment?
*
Yes
No
First Date of Medical Treatment
Total Medical Expenses Out-of-Pocket
Ambulance
*
Yes
No
Ambulance Company
Ambulance Company Phone
Emergency Room
*
Yes
No
Name of ER Hospital
Address
Phone
Other Medical Treatment
*
Yes
No
Name of Medical Clinic #1
Address
Phone
Name of Medical Clinic #2
Address
Phone
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Name of Medical Clinic #3
Address
Phone
Health & Medical Insurance
Private Health Insurance
*
Yes
No
Name of Health Insurer
Employer-Based Health Plan
*
Yes
No
Group/ID Number
Subscriber/Member Number
Medi-Cal Beneficiary
*
Yes
No
Medi-Cal Number
Medicare Beneficiary
*
Yes
No
Medicare Number
Other Health Plan
*
Yes
No
Describe the Plan
Group Number
Member Number
Back
Next
Employment Information
Are You Employed?
*
Yes, I am an Employee
Yes, I am a Business Owner (Self-Employed)
No
Hourly Wage Rate
Amount of Employment Compensation Lost
Name of Employer
Employer's Address
Employer's Phone
Supervisor's Name
Supervisor's Phone
Supervisor's Email
Is there anything else that this Intake Form has not addressed and that you think I should know?
Prior Claims & Litigation
Have you ever made any prior claims for any injuries from an accident?
*
Yes
No
If "Yes," briefly describe each prior claim, including: (A) When claim was made, (B) What happened, and (C) What injuries were sustained.
Prior Medical Treatment
Prior to this accident, have you ever sought medical treatment for the same parts of your body that were injured in this accident?
*
Yes
No
If "Yes," briefly explain, including: (A) Which body parts, (B) When the medical treatment began, and (C) When the medical treatment concluded.
Did this accident affect those prior injuries?
Yes
No
If "Yes," briefly explain how.
Referral Source
How Did You Find Us?
*
Google Search
Yelp.com
Avvo.com
Expertise.com
Facebook.com
Referred By Someone
Other
If you chose "Other," please describe.
*
Referred By:
Please upload the following (as applicable): 1. Property Damage Photos 2. Injury Photos 3. Health Insurance Card 4. Driver's License 5. Medical Records 6. Medical Bills 7. Automobile Insurance Declaration Page 8. Police Report
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