CLIENT INTAKE FORM

CLIENT INTAKE FORM

Auto Accident
DATE OF ACCIDENT:

Month Day Year
Date
REFERRED BY:
PLAINTIFF’S INFORMATION
FULL NAME:
DOB:
GENDER:
S.S.#:
IF UNDER 18, LEGAL GUARDIAN:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:(home)
(work)
(cell)
E-MAIL:
example@example.com
MARITAL STATUS:
SPOUSE’S NAME:
EMERGENCY CONTACT (RELATIVE/FRIEND)
NAME:
PHONE:
ACCIDENT INFORMATION (Get copy of exchange/police report)
EXACT LOCATION OF ACCIDENT:
CITY/COUNTY:
WERE YOU DRIVER PASSENGER PEDESTRIAN
DETAILS OF HOW ACCIDENT HAPPENED:
WERE YOU CITED FOR ACCIDENT?
IF SO, FOR WHAT?
PASSENGERS:
SEATBELT USED?
REPORT MADE?
POLICE DEPT.:
POLICE REPORT CASE #:
HAVE YOU GIVEN ANY STATEMENTS?
TO WHOM?
POTENTIAL WITNESSES:
POTENTIAL WITNESSES:
WERE PHOTOGRAPHS TAKEN? (PLEASE PROVIDE PHOTOGRAPHS)

VEHICLES: ACCIDENT SCENE: INJURIES/SCARS:
PROPERTY DAMAGE
TOTAL PD/ESTIMATE:
TOTAL PD/ESTIMATE:
WHO PAID FOR THE DAMAGES?
IS CLIENT HANDLING PD?
VEHICLE DAMAGES:
WHERE IS THE VEHICLE LOCATED:
DO YOU NEED A RENTAL?

YES NO
DO YOU HAVE COLLISION INSURANCE?

YES NO I DON'T KNOW
DEFENDANT’S INFORMATION
DRIVER'S NAME:

First Name Last Name
AGE:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE #:
PASSENGERS:
TYPE OF VEHICLE:
LICENSE PLATE:
OWNER OF VEHICLE:
WERE THEY CITED?
FOR WHAT?
DEFENDANT’S INSURANCE INFORMATION
COMPANY:
POLICY #:
CLIENT’S AUTO INS. CO.:
POLICY #:
CLAIM #:
UM?
ANY OTHER VEHICLES REGISTERED IN YOUR HOUSEHOLD:
CLIENT’S HEALTH INSURANCE INFORMATION (Upload copy of card)
CLIENT’S HEALTH INS. CO.:
POLICY #:
MEDICARE/MEDICAID?
OTHER MEDICAL COVERAGE?
INJURIES/TREATMENT
CLIENT’S INJURIES (BE SPECIFIC):
CLIENT’S INJURIES (BE SPECIFIC):
DOCTOR:
PHONE #:
CITY/STATE:
DATE OF FIRST TREATMENT:

Month Day Year
Date
DID YOU GO TO THE ER? :

YES NO WAS TAKEN BY AMBULANCE TOOK MYSELF
HOSPITAL NAME:
DATE OF HOSPITAL VISIT?

Month Day Year
Date
LENGTH OF STAY?
ADDITIONAL DOCTORS SEEN:
ADDITIONAL DOCTORS SEEN:
PRIOR MEDICAL HISTORY
PRIOR NECK INJURIES OF ANY KIND (year and description):
PRIOR BACK INJURIES OF ANY KIND (year and description):
ANY OTHER PRIOR INJURIES OF ANY KIND (year and description):
PREVIOUS ACCIDENT, WORK COMP CLAIM OR SLIP & FALLS?
ACCIDENT TYPE:
DATES:

Month Day Year
Date
PREVIOUS LAW SUIT?
EMPLOYMENT
MAKING LOST WAGE CLAIM?
LOST TIME FROM WORK?
DATES LOST FROM WORK IF APPLICABLE
ANYTHING ADDITIONAL YOU NEED TO ADD?
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CLIENT INTAKE FORM

PLAINTIFF’S INFORMATION

EMERGENCY CONTACT (RELATIVE/FRIEND)

PROPERTY DAMAGE

DEFENDANT’S INFORMATION

DEFENDANT’S INSURANCE INFORMATION

INJURIES/TREATMENT

PRIOR MEDICAL HISTORY

EMPLOYMENT