PI - Car Wreck and Injury : Intake Form
Thank you for scheduling with BLWLEGAL GROUP. Please complete this form to the best of your ability. This will allow the legal representative to best assist you on your call back or email.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
E-mail
Date of Birth
*
Driver's License Number and State of Driver's License.
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Are you married? If so, please provide spouse name and contact phone number.
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Occupation
Where are you employed?
Date of Car Wreck or Incident.
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Location of Incident. Address if you have it. (Be Specific).
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Were you deemed to be at fault or not at fault for wreck or incident?
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Not At Fault
At Fault
Unknown at this time
Any details we should know about the at fault driver: (Ex. intoxicated, texting and driving, hit and run, etc.)
Car Wreck Case Only: Do you have car insurance? If so, what insurance company?
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Car Wreck Case Only: Make, Model, and Color of Vehicle you were in?
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Car Wreck Case Only: Make, Model, and Color of Negligent Driver's vehicle?
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Car Wreck Case Only: Do you have Personal Injury Protection Insurance through your Car Insurance?
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Yes
No
Unknown
All Cases: List all Injuries from car wreck or incident.
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All Cases: Have you received medical treatment? If so, where? List all medical providers.
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Do you have Medicare or Medicaid?
Please Select
Yes
No
All Cases: Did the negligent party (in the wrong) have insurance?
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Yes
No
All Cases; List Negligent party's (in the wrong) name and insurance information, if you have it.
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Client's Statement of Car Wreck or Incident: (Include all details)
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Police Report:
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Client's Driver's License:
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Client's Car Insurance:
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Negligent Party Driver's License:
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Negligent Party Car Insurance:
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Pictures of Wreck or Incident / Pictures of Injuries:
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Other Documents Needed:
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How did you hear about BLWLEGAL GROUP?
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Should be Empty: