PERSONAL INJURY INTAKE SHEET
PERSONAL INFORMATION:
Client’s Name
Aliases Date
Address
Phones (H)
(W)
SSN Race: Sex: Age:
DOB:
Married? M S D Resides With:
Phone
Education: Elem H.S. Grade Diploma?
College
Trade School
Spouse’s Name: Phones (H)
(W)
Address
Employer
Children: Name
DOB Age
Name
DOB Age
Father’s Name: Phones(H)
(W)
[ ]L [ ]D Address
Employer
Mother’s Name:
Phones(H) (W)
L D Address Employer
If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and relationships to decedent of the decedent’s immediate family:
Name: Name:
Address: Address:
Telephone:
Telephone:
Relation:
Relation:
Name:
Name:
Address:
Address:
____________________________________________________________________________________Telephone:
Telephone:
Relation:
Relation:
List the addresses where client has resided during the past 10 years and give the period of time at each residence:
Residence Address From/to
EMPLOYMENT INFORMATION:
Name of employer (if unemployed, last employer):
Address of employer:
Telephone number:
Personnel Director/Supervisor:
Job title/type of work:
Present rate of pay: $ (per week/month/year) Hours worked each
week:
Do you regularly work overtime? If so, indicate approximate amount of time & rate of pay:
Do you receive tips or other type of income? If so, indicate:
Type of income Amount Per week/month/year
$ per
$ per
$ per
When did you first begin working for this employer?
If unemployed, when did you leave this employer?
Reason for leaving:
What was your reported income in the year before your accident? $
Were you working for your employer at the time the injury occurred?
Have you applied for worker’s compensation benefits as a result of your accident?
If so, indicate the amounts paid to or received by you to date: $
State your employment history for past ten years:
Name of employer:
Address:
Period of employment:
From To
Position:
Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From To
Position:
Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From
To
Position:
Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From
To
Position: Salary:
Reason for leaving:
Is your spouse employed? If so, indicate:
Employer’s name: Telephone:
Address of spouse’s
employer:
Present rate of pay: $ (per week/month/year) Average yearly income of spouse: $
How long employed with this employer?
List spouse’s employment history for past five years:
Name of employer:
Address:
Period of employment: From
To
Position:
Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From
To
Position: Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From
To
Position: Salary:
Reason for leaving:
Name of employer:
Address:
Period of employment: From
To
Position: Salary:
Reason for leaving:
POLICE RECORD:
Have you ever been convicted of a felony? If so, describe as follows:
1. Date of conviction: Place:
Charge:
Result:
2. Date of conviction: Place: Charge:
Result:
Is there now, or has there ever been, a restriction on your driver’s license?
If so, describe the details of such restriction:
CLAIMS AND LAWSUITS:
Have you ever been involved in any claim or lawsuit, excluding divorce?
If so, list below every claim you have made for money or lawsuits in which you have ever been involved:
Date: Place:
Against whom:
Nature of claim:
Result:
Date: Place:
Against whom:
Nature of claim:
Result:
INSURANCE INFORMATION:
Name of insurance company:
Adjuster’s name: Street address:
Telephone:
City, state, zip:
Policy number:
Do you have insurance covering damage to your car?
Deductible amount: $
How much does your insurance cover if you hurt someone else with your car? $
Uninsured motorist policy limits: Med Pay Amount $
Do you have a second uninsured motorist policy?
If so, fill in the following:
Name of second insurance company:
Address:
City, state, zip:
Claim adjuster’s name:
Telephone: Policy limits: $ Policy number:
Do you have health or accident insurance? If so, indicate:
Name of health insurance company:
Address:
Telephone: Policy #:
Insurance agent’s name:
Name of accident insurance company:
Address:
Telephone: Policy #:
Insurance agent’s name:
Have you ever had insurance of any kind declined or cancelled? If so, give reason:
EDUCATION:
Educational background, listing names of schools attended, addresses, years attended and any degrees obtained:
Name & address of school Years attended Degree
MEDICAL HISTORY BEFORE ACCIDENT
Have you been hospitalized at any time before this accident? If so, list below all hospitalizations:
Date Name of Hospital and Doctor Duration Nature of illness
____________________
____________________
Have you had any physical examinations before this accident? If so, list below all physical examinations for five years before this accident:
Date Name of Doctor Address Purpose
Have you had any accidents or injuries before this accident? If so, list below every such accident or injury and whether there was a claim for damages or not:
Date: Place:
Nature of accident/injury:
Name of treating physician: claim?
Date: Place:
Nature of accident/injury:
Name of treating physician: claim?
Date: Place:
Nature of accident/injury:
Name of treating physician: claim?
Have you had any chronic illnesses or diseases before this accident? If so, list every such illness or disease suffered in the five years before this accident:
Have you had any other chronic health problems or disabilities? If so, list them below:
Did you use any drugs or medication regularly before the accident? If so, list the type of drug and reason f or use:
Have you ever had any broken bones? If so, give date and circumstances:
Date: Circumstances:
Date: Circumstances:
MILITARY BACKGROUND:
Were you in the military service? Dates: from to Type of discharge:
Branch of service: Any service-connected injuries? If so, describe details:
Have you received or do you receive payments from VA, social security or other source?
Claim number:
FACTS OF THE ACCIDENT:
Date: Day: Time:
Weather conditions:
Describe what happened:
DIAGRAM:
Indicate on a diagram in the space below what happened. Write in street or highway names or numbers and show direction of travel by arrows. Also, show north by putting an arrow in a circle:
Show north:
Were seat belts in use in your vehicle? If so, who in your vehicle was using a seat belt and who
was not using a seat belt:
Were police called to the scene of the accident? If so, did the police take photographs of the accident scene? If so, which police department has possession of such photographs?
FACTS CONCERNING THE DEFENDANT:
Name and address of person (defendant) responsible for accident:
Full name of defendant:
Street address:
City, state, zip:
Name of defendant’s employer:
Name of defendant’s spouse:
Name of defendant’s insurance company:
Street address:
City, state, zip:
Adjuster’s name: Phone
Do you know what the defendant’s financial circumstances are without regard to any insurance he might have? If so, specify:
Give your observations about the defendant as a person:
Name of 2nd person responsible for accident:
Street address:
City, state, zip:
Name of 2nd person’s insurance company:
Address: Claim no:
Adjuster’s name: Policy no:
Policy limits: $
Name of 3rd person responsible for accident:
Street address:
City, state, zip:
Name of 3rd person’s insurance company:
Address:
Claim no:
Adjuster’s name: Policy no:
Policy limits: $
OTHER INJURED PARTIES:
Were other parties, other than the defendant, injured in this accident? If so, indicate the following:
Name of 2nd injured party: (2nd plaintiff):
Street address:
Telephone number:
City, state, zip: Birthdate:
Relationship to you:
Name of 3rd injured party: (3rd plaintiff):
Street address:
Telephone number:
City, state, zip:
Birthdate:
Relationship to you:
WITNESSES TO THE ACCIDENT:
List the names, addresses, and telephone numbers of all witnesses to the accident, and any other persons who may be of assistance in testifying about your case, your injuries or changes in your activities since the accident:
Name of 1st witness:
Address: Telephone: Age:
Employment:
Nature of testimony:
Name of 2nd witness:
Address: Telephone: Age:
Employment:
Nature of testimony:
Name of 3rd witness:
Address: Telephone: Age:
Employment:
Nature of testimony:
STATEMENTS MADE:
Have you talked with any police officer, investigator, insurance adjuster or any other person about this incident? If so, indicate to whom you have spoken, the person’s address and telephone number:
Name Address Telephone
Have you given a written or recorded statement to any person about this incident? _____ If so, answer the following:
Name of person to whom statement was given:
Date given: If written, do you have a copy? Persons present at time:
Did you sign the statement?
Did the defendant make any statement to you or in your presence concerning this incident? If
so, indicate what was said and to whom:
When and where was the above statement made?
List the names and addresses of any persons who may have heard it:
Name:
Address:
Name:
Address:
Were any statements about the accident made to or taken from anyone else at the scene of the accident?
If so, describe the name of the person from whom the statement was taken, as follows:
Name: Telephone number:
Address:
Nature of statement:
Name:
Telephone number:
Address:
Nature of statement:
DAMAGES FROM ACCIDENT:
The amount of recovery made in this case will be affected by the injuries, damages or expenses incurred as a result of your accident. It is important that you fully list all information regarding your injuries and your expenses as a result of this accident.
State in full detail all injuries you received as a result of this accident:
State your present physical condition such as scars, deformities, headaches, etc.:
Describe “loss of enjoyment of life” by listing below what normal activities, including sports, hobbies or other activities, you enjoyed before this accident and cannot do now as a result of the accident:
Number of times/week Number of times/week Activity prior to accident Since accident
Have you missed time from work as a result of your injuries?
If so, indicate the following:
From: To: From: To: From: To:
From: To:
Did you lose wages for the periods of time missed from work due to this accident? If so, state the total wages lost to date and the dates:
Wages lost:
Dates:
Wages lost:
Dates:
Have you had any increases or decreases in your pay since the accident?
If so, explain:
Did you lose any promotion or merit increase or fringe benefits due to the accident? If so, describe:
If self employed, have you had to hire anyone to take your place
If so, indicate the costs involved:
If you are a student, indicate time lost from school:
Indicate period of time you were confined to your home:
Indicate period of time you were confined to bedrest:
When is it expected you can return to work?
List any non-monetary compensation you have lost:
Have you been forced to borrow any money as a result of your injuries and inability to work? If so, describe:
Are you able to work part time? If so, where or what kind of work could you do?
List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in this accident:
Name of hospital:
Address: From: To:
Total costs:
Name of hospital:
Address:
From: To:
Total costs:
Name of hospital:
Address:
From: To:
Total costs:
List the full name, address and telephone number of each physician who has examined or treated you for your injuries:
Doctor’s name:
Telephone:
Address:
Specialty:
Type of treatment:
Doctor’s name:
Telephone:
Address:
Specialty:
Type of treatment:
Doctor’s name:
Telephone:
Address:
Specialty:
Type of treatment:
Doctor’s name:
Telephone:
Address:
Specialty:
Type of treatment:
Have you used any of the following in connection with treatment?
Wheelchair ……………….. Dates: From To
Back or neck brace/collar ….. Dates: From To
Crutches …………………. Dates: From To
Traction …………………. Dates: From To
Physical therapy ………….. Dates: From To
Other: Dates: From To
List all medications which you have taken for injuries, the name of the doctor prescribing each medication and length of time you took the medication:
Type of medication Prescribing doctor’s name Length of time
Indicate the amount of all bills/expenses incurred to date as a result of this accident:
$
(attach copies of all such bills, whether paid or unpaid.)
Have you sustained any other injuries since this accident? If so, indicate date,
nature of injury and whether you received medical treatment for said injuries:
Date of injury Nature of injury Medical treatment
PROPERTY DAMAGE:
If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs:
Telephone number: Have you incurred car rental expenses?
$
Where is your vehicle presently located?
If any other personal property was damaged, describe said property:
Total medical & related expenses to date: $ Date:
Total of property damage amount to date: $
Date:
IMPORTANT
Please collect and attach copies of all medical and related bills incurred to date as a result of this accident, indicating which have been paid and which are still due. Please be sure to forward copies of all future medical bills, drug/medication bills, etc., As they are incurred, even if paid by insurance. See the following two pages for list of items to provide to your attorney and a list of general instructions that will require your attention. In completing this intake sheet, have you thought of any information which I have not asked which may be of some assistance to me in representing you? If so, state it on the back of this form no matter how silly, trivial or embarrassing it may seem.
_______________________________________
Client’s signature
Date: _________________________
Attorney Specific Forms
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