POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT IMPORTANT

Transcription

1 POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT Date: Lawyer: Date of Accident: I. CLIENT INFORMATION Client Name: First Middle Last Date of Birth: You would be preferred to be called (nickname): Gender: Male Female If Client Under 18 years of age, Parent s or Guardian s Name: City/State/Zip: Home Work Cellular Fax Number: Driver s License Number: Social Security Number: (Please include the state issued in) (We need this number for our records) Marital Status: Spouse s Name & Number: Two (2) Names and Phone Numbers for Emergency Contacts: 1) 2) Please provide your screen name(s). FACEBOOK name: TWITTER name: MySpace name: Other internet name: IMPORTANT *SOCIAL NETWORKING SITES: Any information about you on social networking sites (i.e., Myspace, Facebook, blogs, etc.) is readily available for the insurance company(ies). It is a means for them to evaluate your personality, credibility, and character. You can guarantee that an insurance company and its legal representatives will search these sites and the web in general for information they can use against you to avoid or limit payment. Therefore, you must remove and refrain from placing any content that could paint you in a negative light. HOW DID YOU HEAR ABOUT OUR LAW FIRM? Attorney s Signature: Who Can We Thank For The Referral? (Please check all that apply.) TV Yellow Pages Seminar Website / Internet By An Attorney By A Friend You Were / Are a Current / Previous Client By A Physician Reputation By A Previous / Current Client Bus Stop Signs Drive By / Walk In (Outdoor Sign) Answering Service Other LANGUAGE PREFERENCE English Spanish Other:

2 II. EMPLOYMENT INFORMATION/WORK ABSENCE Were you on the job at the time of the collision? (select one) Yes or No Employer s Name: City/State/Zip: Your Job Position: Your Supervisor: Have you lost any wages? How much do you make per hour or by salary? Avg. tip? Commission? Other? How many hours per day do you work? Time lost from work: Days Hours Will you lose further time from work? Do you have a Doctor s excuse? (Provide a copy to the attorney) Social Security and Social Services Information: 1. Have you been determined to be disabled? (select one) Yes or No When? 2. If you answered No to No. 1, have you applied for social security disability? (select one) Yes or No When? 3. Do you receive public assistance based on your level of income? (E.g., Medicaid, social services, Social Security Supplemental Income or SSI, county assistance programs, food stamps, etc.) (select one) Yes or No 4. If you answered Yes to No. 3, what public assistance do you receive? III. HEALTH INSURANCE INFORMATION Primary Health Insurer (e.g., Medicare, HPN, Culinary): Member No: Secondary Health Insurer (e.g., AARP, Senior Dimensions): Member No: Would you like for your medical provider(s) to bill your health insurance? (select one) Yes or No (Please provide our office with a copy of the front and back of your insurance cards.) IV. ACCIDENT INFORMATION (Please continue below in section K if you need more room) A. Health Care Providers (Ambulance, Hospital, Doctor, Chiropractor, Physical Therapy, Pharmacy, etc.): 1. Name: 2. Name: 1

3 3. Name: 4. Name: 5. Name: Please bring list to office if there are additional medical providers. Or put information in section "K" below. B. Injuries from Current Accident: C. Wrongdoer/Defendant Information & Defendant s Auto Insurance Information: 1. a. Name of Driver: b. (If Different) Name of Owner: 2. a. Name of Driver: 2

4 b. (If Different) Name of Owner: 3. Have you given a Recorded Statement? If so, when and to whom given? D. Your Auto Insurance Information: 1. Your Auto Phone Number 2. If Different, Auto Insurance Carrier of Vehicle s Owner: 3. If Different, Auto Insurance Carrier of Vehicle s Driver: 4. If Different, Auto Insurance Carrier of relative you resided with at time of accident: E. Facts of Accident Date: Time: Place: Weather: Speed Limit: Your Speed: Wrongdoer s Speed: What was the purpose of your trip? (e.g., going to/from work, personal errand, taking kids to/from school/babysitter, etc.) 3

5 Skid marks by your vehicle? Wrongdoer s Vehicle? Did Police Respond? If Police Responded, Which Dept? Incident #: Did you give anyone a Statement (If yes, to who? When? Verbal? Written?) If No Police Report filed, why not? Citations: Whom Cited and For What? Location of damage to your vehicle: Estimate of Repair: $ Repaired? By Whom? Actual Cost of Repair: $ If vehicle totaled, by who? What value given? $ Where is your vehicle currently? Location of damage to Wrongdoer s vehicle: If Photographs taken of either vehicle, by whom? If Photographs taken of you, by whom? Of what? Facts of Incident: Diagram of Incident: Indicate vehicles by number as in police report, indicate direction if known <> Were you the driver or passenger? If passenger, name of driver: Witnesses: 1. Name: Relation to you: 2. Name: Relation to you: 3. Name: Relation to you: F. Prior Accidents or Injuries (e.g., Auto, Slip and Fall, On the Job, etc.): DATE DESCRIPTION INJURIES DOCTOR/HOSPITAL, ETC

6 G. Prior Similar or Same Pain, Conditions or Treatment (e.g., back/neck/shoulder/knee pain; surgery): H. Criminal History: Have you been convicted of a felony or been released from parole within the last 10 years? I. Have you seen a doctor for any reason in the last year? J. Who is your primary care doctor? K. Other: Please state any other information you feel that we should be aware of: Thank you for taking the time to fill out this form. Please save the form and upload to our website client intake form. You'll have to upload it as an attachment: 5