Client Intake Form - Personal Injury... 1 of 6
Please print out and fill out the form below. Feel free to use additional pages if needed. For clarity, please label continuation responses according to section and item numbers.
PERSONAL INJURY INTAKE
I. CLIENT INFORMATION
Client Name
First Name
Middle Initial
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Pager/Cell Phone:
Format: (000) 000-0000.
E-mail:
example@example.com
Pedigree
Marital/Guardian Status
Spouse:
Guardian:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
Child:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Critical Deadlines:
City/Public Authority Involved?
Yes
No
Notice of Claim Deadline:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Statute of Limitations:
Automobile Accident Client Interviewed By:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Source:
File No.:
II. EMPLOYMENT INFORMATION
Employer:
Client's Occupation:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Weekly/Biweekly Salary:
Date Employment Commenced:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
No. of Hours Worked Per Day:
No. of Day Worked Per Week Week:
Supervisor:
First Name
Last Name
Phone No.:
Format: (000) 000-0000.
Last Day Worked Before Accident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Returned:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Light/Restricted Duty?:
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Client Intake Form – Personal Injury... 2 of 6
How Long Were You Confined To Bed:
How Long Were You Confined Home:
Employer's Disability Carrier:
Address of Employer's Disability Carrier:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Disability Carrier's Policy No.:
Workers Compensation Carrier:
Address of Workers Compensation Carrier:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
WCB Carrier Case No.:
III. EDUCATION
School Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level:
IV. ACCIDENT INFORMATION
Date of Accident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Day:
Time:
Hour Minutes
AM
PM
AM/PM Option
Location Of Accident:
Client Was Traveling On What Street/Road:
Offending Vehicle Was Traveling On What Street/Road
Weather:
Plaintiff's Position In Vehicle:
Accident Description:
Precinct:
Accident No.:
Officer's Name:
First Name
Last Name
Officer's Badge No.:
V. Diagram Of The Accident:
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VI. WITNESSES
Witness #1 Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Witness #2 Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Witness #3 Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
VII. VEHICLE INFORMATION
Client Role in Accident
Our client was the in vehicle # 1 (Owner/Operator/Passenger)
Our client was a pedestrian.
Vehicle No. 1: (Host Vehicle)
Vehicle Plate No.:
Vehicle's Year:
Vehicle's Make:
Vehicle's Model:
Vehicle's VIN #:
Owner's Name:
First Name
Last Name
Owner's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Leaseholder's Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Operator:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Carrier/Insurance Code:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder:
First Name
Last Name
Policy No.:
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