GENERAL BACKGROUND INFORMATION 1
What is your name?
2
What is your age?
3
What is your mobile cell phone number?
4
What is your home phone number?
5
What is your e-mail address?
6
What is your street address?
7
What is your Social Security Number?
8
What is your California Drivers License Number?
9
What is your Date of Birth?
GENERAL CASE INFORMATION
10
Date of Incident/Accident Causing Injury?
11
Where did the accident/incident take place? (City, County, State, Street Address)
13
Describe how the accident/incident occurred:
Car Accident
Motorcycle Accident
Train Accident
Pedestrian Struck by Vehicle
Slip & Fall
Assault
Other
13
Was there a police report or written report generated? If yes, list the report number and agency that wrote the report.
14
Were there any witnesses to the accident/incident? If yes, list their names, addresses, telephone numbers and descriptions.
15
List all parties that were involved in the accident/incident: (For example, the other driver, the manufacturer, the store or property location, the medical care provider, the owner of the dog, etc.)
16
Who do you believe was at fault for the accident/incident? (For each party named, describe how they were at fault.)
INJURY INFORMATION
17
What type of injury did you sustain?
Muscle Strain/Sprain Broken Bone
Internal Injury Emotional Injury
Wrongful Death of a Spouse / Family Member
Headaches
Dizziness/Nausea/Vomiting
Loss of Memory or Cognitive Function
Other
18
Describe your injuries in detail.
19
Have you ever suffered any type of similar injury before? If yes, describe in detail.
20
Have you ever had a claim, case or settlement for any type of claim arising from Negligence, Automobile Accident, Motorcycle Accident, Bicycle Accident, Pedestrian Accident, Slip-n-Fall Accident, Products Liability, Assault & Battery, Wrongful Death, Medical Malpractice, Dog Bite, or Other (Please Describe)
21
Please list the name, address, telephone number of every medical care provider you have seen for your injury: (Including ambulance, emergency room, x-ray or diagnostic imaging, family or primary doctor, specialists, physical therapists, chiropractors, psychologist, psychiatrist, or other)
22
Chronology: Please provide the Date of the accident/incident, the date you first sought medical care, the date of each subsequent visit for medical care, and the date of any other event or fact that you consider to be significant:
23
List the name, address, telephone number and injuries of anyone else that was injured in the accident/incident:
24
Describe any documents that you believe support your case?
INSURANCE INFORMATION
25
Did you have automobile insurance at the time of the accident/incident?
Yes
No
26
Were you living with anyone who had automobile insurance at the time of the accident/incident?
Yes
No
27
Did you have homeowners/renters insurance at the time of the accident/incident?
Yes
No
28
Were you living with anyone who had homeowners/renters insurance at the time of the accident/incident?
Yes
No
29
Did any other party involved in the accident/incident have insurance?
Yes
No
DAMAGES
30
Please list all medical bills you have incurred to date relating to the incident: (It does not matter if insurance paid the bills, list them)
31
Describe all property loss resulting from the accident/incident (damage to your vehicle, your possessions, etc):
32
Describe all financial loss resulting from the accident/incident (medical bills, lost wages, lost income, lost opportunities, etc): If you have any doubt as to whether or not something is a loss that may be recovered, list it):
33
Were you working at the time of the accident/incident?
Yes
No
PRIOR CIVIL OR CRIMINAL LITIGATION OR CLAIMS
34
Have you ever filed a lawsuit before or have you ever been sued before
Yes
No
35
Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future?
Yes
No
36
Have you ever been arrested?
Yes
No
37
Have you ever filed a workers compensation claim for any injuries sustained at work?
Yes
No
