Personal Injury Intake
(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!

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

PERSONAL INFORMATION

Contact information

Social Security #

Driver’s License

Spouse’s full name, if married

Military Service?

ACCIDENT INFORMATION

Is this an auto accident?

Driver or Passenger?

Please give driver’s full name

Date of incident

Time of Incident: AM or PM?

City of incident

County of incident

Road/Intersection (if applicable)

Were the police called to the scene?

Was an accident or incident report filed?

If the Police DID NOT file an accident report, did you file a blue form?

Describe how the incident occurred

Photo / Diagram upload

OTHER PARTY

Name of the other party

Address

Phone number

His / Her job

His / Her age

His / Her insurance company

His / Her insurance adjuster

His / Her insurance coverage

Do you know what the other party’s financial circumstances are without regard to any insurance he/she may have?

Give your observations about the party as a person

How did the defendant’s car leave the scene?

AUTOMOBILE INFORMATION

What is the make, model, and year of your car?

Who was the operator of your car?

What is the license plate number of your car?

What was the damage to your car?

Did you have to rent a car?

What is the make, model, and year of the other party’s car?

Who was the Operator of that car?

What was the license plate number of that car?

What was the damage to that car?

Who investigated the accident?

Describe the point of impact for each auto

How far did the cars travel after impact?

Position of vehicles after impact

How did you leave the scene of the accident?

PASSENGERS

Passenger 1:

Passenger 2:

Passenger 3:

Passenger 4:

Passenger 5:

Additional:

WITNESSES

Witness 1:

Witness 2:

Witness 3:

Witness 4:

Witness 5:

Additional:

STATEMENTS MADE

Have you told any police officer, investigator, insurance adjuster or any other person about the collision? Please list each person and the entire substance of your statement.

YOUR AUTOMOBILE INSURANCE INFORMATION

Name of your auto insurance carrier

Name of policy holder

Policy number

Agent / adjuster

Telephone number

Claim number

Type of coverage

PIP limits

INJURIES

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

Check symptoms you have noticed since the accident

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?

INJURY HISTORY