PERSONAL INJURY

Client Member Name* This field is required.Please type your name as it appears on your legal ID (DL/Passport)

Prefix

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 initialling the box below, you knowingly, intelligently consent to everything in this paragraph.

First Name

Middle Name

Last Name

Client Member Phone Number* This field is required.

Area Code

Phone Number

Member ID:Legal plan members only

Member Legal Plan / referral sourcePlease select one

MetLife

ARAG

Yelp

Google

Another attorney

Former client

Other

Case Assist No. / Eiligibility No.:Legal Plan members only, please put your case number below

Last 4 of your SS#Legal plan members only, please put the last 4 of your social below

Client Member Email* This field is required.

example@example.com

Client Member birth date* This field is required.

Date

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

Client Member Spouse's Name, if anyIf Married

Prefix

First Name

Middle Name

Last Name

Suffix

Client Member home address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

The Business Name, address, and phone of your employer

Client Member Job Title, date of hire, and annual salary

Were you in the course and scope of your job when the injury/breach occurred?If so, please explain your work hours and duties

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

Approximate date of the incident/breach/injury* This field is required.

Date

Approximate time of incident/breach/injury

Hour

Minutes

Name and contact info of witnesses, if any

What type of incident is this about?* This field is required.Mark all that apply

Battery between two or more individuals / fist fight / bar fight / attack

Slip and fall / premise liability

Sexual assault

Medical / Dental Malpractice

Burn

Product liability / Other

Breach of contract / fraud

Car accident

Property dispute

Other

Which services are you considering?* This field is required.Mark all that apply

Document review and consultation

Small Claims for breach of contract

Small Claims for personal injury

Other

Is either person or the place involved a government entity or government employee?* This field is required.Mark all that apply

Yes, Federal

Yes, State

Yes, County or local city

I don't know

Other

How many people injured people in your group? If a breach of contract, ignore this section

Just myself

Me and another person

Me and two others

Three or more

The contact info of the party and/or business who caused you harmName, address, manager name and contact, etc.

Police report?

Yes, local police

Yes, OC Sherrif

Yes, LA Sherrif

No Police report

Other

Please provide all insurance information and contact info of adjusters, if any.Business Insurance, Personal Insurance, Umbrella Insurance, etc.

If there are physical injuries, describe the extentMark all that apply

Describe the incident and timeline of eventsWhat, when, where, how, why

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

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 DUI within 5 years

Over 1 DUI

No, never

Other

Upload all photos and documents you have associated with your accident, including contracts, insurance declaration pages, medical reports, 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 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

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

Email nights / weekends

Text / IM daily

Text / IM nights / weekends

Phone daily

Phone 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

If this is related to an accident, 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

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.

All cases at our firm have an administrative fee of $50 to pay for basic necessities related to your case. Please type your name here to agree to this fee. Once you agree and we receive payment we can begin working. We accept zelle using Jlee@lowcostwillsandtrusts.com or Josh@lawandevidence.com.

We are sometimes 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 to get things started.

PERSONAL INJURY - OTHER