intake form

Personal Information

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

Email

● Date of Birth (DOB):

of fault? the

● Social Security #:

● How did you hear about us?

● Referred by whom?

● Do you have any children? How many?

● Any bankruptcies, child support, or alimony?

● Any pre-existing medical conditions?

● Do you own a home or rent? How long have you lived there?

● Date of accident:

● Whose fault? Any witnesses?

● Did police come to the scene? Do you have a police report?

● Did you go to the hospital or doctor the same day?

● What are your injuries?

● Any X-rays, MRIs, injections, or surgeries?

● Are you still treating? With whom? (Include phone #)

● Are you the owner or driver of the car?

● Any passengers? How many? Were they injured?

● Name of your insurance company:

● Name of at-fault driver’s insurance company:

● Any citations issued? Was liability accepted?

● If it isn’t an auto accident, how did you get hurt?

● Can you prove loss of income? How much?

● Company you are employed by?

● Were you paid as a salaried employee or subcontractor?

● Name of law firm & attorney handling case (phone/email):

● Name of paralegal:

● Any other personal injury cases within the last 5 years (settled or pending)?

● Attorneys on the previous cases?

● Any other accidents within the last 5 years?

● Name of other funding company (if any):

● Liability accepted? Any offers made?

● Was a suit filed? In what state & county?

● Any mediation date scheduled?