Intake Form

Law Offices of Kevin Anderson Attorney at Law

REFERRED BY

REFERRAL DATE

Date

DATE OF ACCIDENT

Date

Time

Hour Minutes

AM/PM Option

WEATHER

LOCATION/INTERSECTION OF ACCIDENT

NAME

DOB

GENDER IDENTITY

Home Number

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

ADDRESS

EMAIL ADDRESS

example@example.com

Your Social Security Number SSN #

Spouse / Parent Name:

Spouse Parent SSN#:

Spouse/ Parent Drivers Licence #

Spouse or Parent Date of Birth

Date

Are you on Medi-CAL

YesNo

If Yes: Member ID

Are you on Medicare:

YesNo

If Yes: Member ID

ARE YOU RECEIVING SSD (Social Security Disability):

YesNo

HAVE YOU APPLIED FOR SSD( Social Security Disability):

YesNo

ARE YOU RECEIVING SSI (SUPPLEMENTARY SECURITY INCOME)

YesNo

HEALTH INSURANCE PROVIDER

HEALTH INSURANCE POLICY NUMBER:

TYPE OF VEHICLE

LICENSE PLATE #

INSURANCE CO. OF OWNER OF CAR

POLICY #

CLAIM #

DOES A RELATIVE RESIDING IN CLIENT’S HOUSEHOLD OWN A CAR?

COLLISION INS. ?

Law Offices of Kevin Anderson Attorney at Law

EMPLOYER’S NAME

PHONE

JOB DESCRIPTION

WAGES

HOW MANY DAYS PER WEEK

HOW LONG EMPLOYED THERE

HOW MANY HOURS A DAY

OFF FROM WORK

DEFENDANT

A OWNER

INSURANCE CO

ADDRESS

POLICY #

B DRIVER

CLAIM #

TYPE OF VEHICLE

LICENSE PLATE #

FACTS OF ACCIDENT

HAVE YOU EVER BEEN INVOLVED IN A LAWSUIT OR WORKER’S COMPENSATION CLAIM BEFORE?

	VEHICLES	DIRECTION	STREET NAME	SPEED	CLIENT

IF YES, EXPLAIN

DID ACCIDENT OCCUR IN COURSE OF EMPLOYMENT?

WERE THERE PASSENGERS IN THE CAR?

Law Offices of Kevin Anderson Attorney at Law

NAME

WITNESS:

PHONE #

REPORT #

DO YOU HAVE PHOTOS TAKEN OF THE SCENE OF ACCIDENT?

DID YOU HAVE ANY PHYSICAL COMPLAINTS/DISABILITIES BEFORE THE ACCIDENT?

IF YES, EXPLAIN

DESCRIBE INJURIES FOLLOWING THE ACCIDENT

WHEN AND WHERE DID YOU RECEIVE MEDICAL TREATMENT FOLLOWING THE ACCIDENT?

HOW LONG WERE YOU IN THE HOSPITAL?

DOCTORS YOU HAVE SEEN FOR YOUR INJURIES

WHEN WAS THE DOCTOR FIRST SEEN?