Personal Injury Initial Interview Form

Background Information

First name: MI: Last name:

Maiden name, former names and/or aliases:

Address:

City: State: Zip:

Home Phone: Work Phone:

*Email Address:   

Other means of contact:

Marital status: Single Married Divorced

Spouse's full name, if any:

Number of children living at home under age 18:

Date of Birth: / /

Nationality:

Military backround (if any) (bring in your DD214):

Your Own Car/Homeowner's Insurance Information

Insurer name: / Adjuster:

Address:

City: State: Zip:

Phone:

Have you made a claim on your own insurance for this accident? Yes No

Is your car insurance, homeowner's insurance or other insurance company paying your car/property damages for this accident? Yes No

Is your car insurance, homeowner's insurance or other insurance company paying your medical bills for this accident? Yes No

Personal Health Insurance Carrier Information

Insurer name:

Address:

City: State: Zip:

Phone:

Has this carrier paid any bills to date for this injury? Yes No

Accident Information

Date of accident: / /

Description of injury (Body part(s) injured):

How did the accident occur?

Witnesses (i.e., passengers, bystanders...) (Please include name, address, and phone number):

Witness 1:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Witness 2:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Witness 3:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Did you give a verbal/written statement regarding this injury? Yes No

If so, state to whom given and date given: Date: / /

Was a traffic citation issued as a result of this accident? Yes No

If so, who received citation and what was the disposition, if known?

Were any photographs taken of the accident, accident scene, injuries and/or any vehicles involved in the accident? Yes No

Your Vehicle/Property Damage Information

Who is the registered owner of the vehicle you were driving/riding in at the time of this accident?

Owner #1 full name: MI: Last name:

Owner #2/Co-Owner full name, if any: MI: Last name:

Did your vehicle sustain property damage as a result of the accident? Yes No

Did you or anyone else take pictures of the property damage (If yes, please bring the pictures to your first appontment)? Yes No

If so, have you received any estimates on the extent of property damage? Yes No

Please state the full name and address of the agency(s) making the estimate(s), and the amount(s):

1. Name: Address: Amount

2. Name: Address: Amount

3. Name: Address: Amount

Opposing Party Information (Other Driver)

First name: MI: Last name:

Address:

City: State: Zip:

Opposing party insurance information:

Insurer name: / Adjuster:

Address:

City: State: Zip:

Phone:

Is the opposing insurance company paying for your car or property repairs or for your medical bills arising from this accident? Yes No

Treatment of Injury

Medical providers (Please list names/addresses of doctors, therapists AND hospitals, if possible):

1. Name: Address:

2. Name: Address:

3. Name: Address:

4. Name: Address:

5. Name: Address:

Outstanding medical expenses (i.e. pharmacy, mileage, doctors,...) (Who owed and amount):

1. Name: Amount:

2. Name: Amount:

3. Name: Amount:

4. Name: Amount:

5. Name: Amount:

Nature and extent of permanent disability (if already known):

Nature and extent of permanent disability of any Prior physical or mental injuries or health problems:

Employer Information

Last or Current Employer:

Address:

City: State: Zip:

Phone:

Position or bid job: Supervisor or Foreman:

Date employment began: / / Date last worked: / /

Salary/Hourly wage rate (at time of accident): $

Lost wages (as result of accident): $

Additional Information

To aid the location of improtant records

Place of birth:

Former/Past Residences (in reverse order):

1.

2.

3.

4.

5.

Church Affiliation

Vocational Information

Please state the school names, dates attended, location and last grade completed.

Elementary School(s)

Junior High/High School(s)

Date graduated: / /

GED: Yes No Date: / / Location:

Vocational, military and/or further training (if any):

Criminal History

Do you have any prior criminal convictions? Yes No

If yes, please explain:

Medical History

Past physical and mental medical treatment, names and addresses if possible:

1. Treatment: Name: Address:

2. Treatment: Name: Address:

3. Treatment: Name: Address:

4. Treatment: Name: Address:

5. Treatment: Name: Address:

6. Treatment: Name: Address:

7. Treatment: Name: Address:

8. Treatment: Name: Address:

Third Party Information/Insurance

(i.e. Accident caused by a second party or corporation)

Name:

Address:

City: State: Zip:

Phone:

Insurance carrier information:

Insurer:

Address:

City: State: Zip:

Phone:

Adjuster:

NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent. I agree that submitting this form does not create an attorney-client relationship and that the information I am providing may be used to check for conflicts of interest to determine if the firm can assist me with my legal inquiry.

*I Agree:   

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