Knabe Law Firm Co., LPA
Personal Injury
Intake Form - Pedestrian
Complete this form and click the SUBMIT button at the bottom.
Client Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Client Social Security Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear of us?
Are you on Social Media?
Facebook
Twitter
TikTok
Instagram
LinkdIn
Other
Are your Social Media accounts set to public or private?
Public
Private
Don't know
Highest Level of Education Completed
High School
Some College
College Degree
Post doctoral studies
Client's Occupation
Client's Employer's Name and Contact Information
Is this a Worker's Compensation claim?
Yes
No
BWC case number
Did you miss work due to accident?
Yes
No
If yes, what dates did you miss work?
Did your experience lost wages?
Yes
No
Amount of lost wages
Are you married?
Yes
No
Date of marriage.
If married, name of spouse.
Spouse's Date of Birth
Spouse's Social Security Number
Spouse's Occupation
Spouse's Employer
Do you have children?
Yes
No
Childrens' names and ages
Date of Accident
Time of Accident
Weather at time of Accident
Location of Accident
Was a police report made?
Yes
No
Police Department that made the report
Purpose for your trip
In your own words please describe how the accident happened
Names of Tortfeasor
Tortfeasor's insurance carrier
Has a claim been opened with the Tortfeasor's insurance carrier?
Yes
No
Unknown
Tortfeasor insurance claim number
Adjuster's name and phone number
Did you give any statements to Tortfeasor or their insurance company?
Yes
No
If yes, please describe
Did anyone witness the accident?
Yes
No
Unknown
Names and contact information of all witnesses
Client's auto insurance carrier
Client's auto insurance policy number
Have you opened a claim with your insurance carried for this accident?
Yes
No
Client's insurance claim number
Adjuster name and phone number
Do you have Underinsurance/Uninsured motorist coverage?
Yes
No
Unknown
Underinsurance/Uninsured motorist coverage amount.
Do you have Medical Payments coverage on your auto policy?
Yes
No
Unknown
What is your Medical Payments limits?
Did you go to the ER due to this accident?
Yes
No
If you went to the ER, please list name of party that took you (EMS, Friend/Family/Drove Self)
Which Hospital ER did you seek medical treatment?
Were you released the same day from the ER?
Yes
No, was admitted
Didn't go to ER
Select all the injuries you were diagnosed with at the ER
Neck/Head Pain
Arm/Wrist Pain
Leg/Knee Pain
Foot/Ankle Pain
Shoulder Pain
Hip Pain
Broken Bone(s)
Internal Injuries
Other
Please describe all your injuries
Draw on Image
Have you treated with anyone besides the ER?
Yes
No
Please list the name and location of all doctors you have treated with besides the ER due to this accident.
Name of your health insurance provider
Health insurance policy number
Health insurance contact information
Have your bills been submitted to your health insurance? (explain subrogation)
Did a family member provide attendant care?
Have you been involved in a prior accident?
Yes
No
Please describe all prior accidents, your injuries from them and any legal action resulting from the accident.
Do you have any prior lawsuits, current lawsuits or pending litigation?
Yes, civil
Yes, criminal
Yes, bankruptcy
No
If you answered yes to the above question please explain.
As a result of this accident, how has your life changed? Are you unable to do certain activities?
Additional notes.
Make and model of vehicle that hit you
Describe the location and extent of damage to the motor vehicle
Did you take photographs of the damaged vehicle?
Yes
No
Date Submitted
-
Month
-
Day
Year
Date
Submit
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