Personal Injury Intake
(Non-Auto Accident)

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

CLIENT INFORMATION

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

ACCIDENT INFORMATION

OTHER PARTY

WITNESSES

For each witness, please select "Yes" and fill out the following information.

STATEMENTS MADE

INJURIES

SYMPTOMS

PAST INJURIES

For each past injury, please select "Yes" and fill out the following information.

LOSS OF EARNINGS

If you anticipate loss of earnings due to accident related injuries, please complete the following.

ADDITIONAL INFORMATION

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

CLIENT INFORMATION

Contact information

Social Security Number:

Driver's License Number:

Married?

Military Background?

ACCIDENT INFORMATION

Is this an Auto Accident?

Date of Incident:

Time of Incident:

City of Incident:

County of Incident:

Road/Intersection:

Were the police called to the scene?

Your understanding of how the incident occurred.

Photo / Diagram Upload:

OTHER PARTY

Name of Other Party:

Other Party's Address:

Other Party's Phone Number:

Other Party's Job:

Other Party's Age:

Other Party's Spouse/Partner:

Other Party's Insurance Company:

Other Party's Insurance Adjuster:

Other Party's Insurance Coverage:

Give your observations about the party as a person.

WITNESSES

Witness #1:

Witness #2:

Witness #3:

Additional Information:

STATEMENTS MADE

Have you told any police officer, investigator, insurance adjuster or any other person about the accident?

INJURIES

Please describe any and all aches, complaints, discomforts and disabilities, as a result of accident related injuries, in detail.

Did you go to the hospital?

Did you go by ambulance?

Did they take x-rays?

Have you seen a doctor since the date of the accident, other than at the emergency room

Have you had any accidents or injuries before this accident?

For this accident or injury, was there a claim filed for damages?

SYMPTOMS

Nature of Accident Injury Treated By CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT

PAST INJURIES

Past Injury #1:

Past Injury #2:

Past Injury #3:

Past Injury #4:

Additional Information:

LOSS OF EARNINGS

Employer:

Your Position or Title:

Rate of Pay:

How many hours do you normally work per week?

ADDITIONAL INFORMATION

Any additional Information you think would be helpful.

ACKNOWLEDGEMENT AND ACCEPTANCE:

THANK YOU