Client Questionnaire

MOTOR VEHICLE ACCIDENT

PERSONAL INJURY CLIENT QUESTIONNAIRE 

Instructions: Please fill out the following questionnaire as best you can.  I know that there are many requests for information that you may not have or that may not be applicable to your case. If such is the case, simply skip those questions.  However, the more information you provide me with the better job that I can do for you on your case.  Therefore, the more you put into filling out this questionnaire, the better chance you will have of being successful with your case.

PERSONAL INFORMATION

Names:                                                                                                          

Address:

                                                                                                                       

                                                                                                                  

Telephone No.’s:(home)           ___            (work)     _                 (other)                  

Social Security Numbers:                                                  

Driver’s License Number and State of Issuance:                                                                     ____________________

Date of Birth:                                

Height:   ____    Weight:    ___   Age:   ____    Race:                         

Marital Status:                    

Name and Age of Spouse if Any:                                                                                              

Names and Ages of Children if Any:

                                                                                                                          

                                                                                                                           

                                                                                                                            

                                                                                                                           

YOUR AUTOMOBILE INSURANCE INFORMATION

Name of Your Automobile Insurance Company:                                                                       

Policy Number:                                                                                                    

Address of Insurer:

                                                                                                                                     

                                                                                                                                      

Medical Payments Provision Coverage and Amount of Same:                                                 

Has Medical Payments Provision Coverage Been Used:                                                          

Attach Copy of Your Automobile Insurance Policy if You Have: (__)Yes    (__) No

Uninsured Motorist Coverage: (__) Yes    (__)  No     Limits of Coverage:                                  

Number of Cars Covered Under Policy or Policies:                                                                  

Number of Automobile Insurance Policies Owned by You:                                                     

Automobile Insurance Agent:                                                                                                    

Agent’s Phone Number:                                       

Agent’s Address:

                                                                                                                               

                                                                                                                             

Adjustor:                                                                                               

Adjustor’s Phone Number:                                   

Adjustor’s Address:

                                                                                                                          

                                                                                                                          

Uninsured Motorist Claim Numbers:                                                                                         

Comments about Insurance Coverage:                                                                                      

 MOTOR VEHICLE INFORMATION

 Please give the name, address, and telephone number for the owner of the automobile you occupied at the time of the accident:

                                                                                                                             

                                                                                                                             

Please give the make, model, and year of the motor vehicle you occupied at the time of the accident:

                                                                                                                         

Please give the name of the automobile insurance company which insured the motor vehicle you occupied at the time of the accident:

                                                                                                                             

How much uninsured motorist coverage existed on the motor vehicle you occupied at the time of the accident?

                                                                                                                          

How much medical payments coverage existed on the motor vehicle you occupied at the time of the accident?

                                                                                                                           

 OTHER PARTIES INVOLVED

 Please identify all other parties involved including the name of the person who was at fault.  Also, please indicate whether they were injured in this accident if you know.

PARTY NUMBER ONE:

Name:                                                                                                           

Address: _________________________________________

                                                                                                                                 

Telephone No.’s:(home)                       (work)                      (other)                     

Social Security Number:                           

Description:                                                                                                  

Statements made by this person at time of accident:

                                                                                                                           

                                                                                                                           

                                                                                                                           

Make, Model and Year of Automobile driven by this person:

                                                                                                                     

Automobile Liability Insurer:                               

Policy Number:                                     

Adjustor:                                                   

Adjustor’s Phone Number:                               

Automobile Liability Insurer’s Address:

                                                                                                                    

                                                                                                                    

                                                                                                                    

Limits of Coverage:                                                                                                                   

Settlement Offers:                                                                                                                     

Claim Number:                                                                                                                           

Party’s Employer, Address, and Telephone Number if Known:

                                                                                                                              

                                                                                                                               

                                                                                                                        

Was this Party working at the time of the incident (__) Yes   (__)  No

Was this Party at fault, and if so, please state how he/she was at fault:

                                                                                                                                

                                                                                                                                 

Was this Party injured, and if so, please describe the extent of their injuries:

                                                                                                                               

                                                                                                                               

 PARTY NUMBER TWO:

Name:                                                                                                                   

Address:

                                                                                                                             

                                                                                                                              

Telephone No.’s:(home)                          (work)                      (other)                           

Social Security Number:                           

Description:                                                                                                 

Statements made by this person at time of accident:

                                                                                                                            

                                                                                                                           

                                                                                                                          

Make, Model and Year of Automobile driven by this person:

                                                                                                                          

Automobile Liability Insurer:                               

Policy Number:                                     

Adjustor:                                                   

Adjustor’s Phone Number:                               

Automobile Liability Insurer’s Address:

                                                                                                                        

                                                                                                                        

                                                                                                                       

Limits of Coverage:                                                                                

Settlement Offers:                                                                                                                     

Claim Number:                                                                                                                           

Party’s Employer, Address, and Telephone Number if Known:

                                                                                                                          

                                                                                                                           

                                                                                                                       

Was this Party working at the time of the incident (__) Yes   (__)  No

Was this Party at fault, and if so, please state how he/she was at fault:

                                                                                                                                     

Was this Party injured, and if so, please describe the extent of their injuries:

                                                                                                                                  

                                                                                                                                     

                                                                                                                                   

 PARTY NUMBER THREE:

 Name:                                                                                                                     

Address:

                                                                                                                           

                                                                                                                             

Telephone No.’s:(home)                       (work)                      (other)                     

Social Security Number:                                       

Description:                                                                                                     

Statements made by this person at time of accident:

                                                                                                                                

                                                                                                                               

Make, Model and Year of Automobile driven by this person:

                                                                                                                            

                                                                                                                              

Automobile Liability Insurer:                               

Policy Number:                                     

Adjustor:                                                   

Adjustor’s Phone Number:                               

Automobile Liability Insurer’s Address:

                                                                                                                        

                                                                                                                       

                                                                                                                      

Limits of Coverage:                                                                                                                   

Settlement Offers:                                                                                                                     

Claim Number:                                                                                                                           

Party’s Employer, Address, and Telephone Number if Known:

                                                                                                                         

                                                                                                                         

                                                                                                                        

Was this Party working at the time of the incident (__) Yes    (__) No

Was this Party at fault, and if so, please state how he/she was at fault:

                                                                                                                                                   

                                                                                                                                                   

Was this Party injured, and if so, please describe the extent of their injuries:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

 PARTY NUMBER FOUR:

 Name:                                                                                                                                     

Address:

                                                                                                                                                   

                                                                                                                                                   

Telephone No.’s:(home)                       (work)                      (other)                     

Social Security Number:                                       

Description:                                                                                                                            

Statements made by this person at time of accident:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

Make, Model and Year of Automobile driven by this person:

                                                                                                                                               

Automobile Liability Insurer:                                           

Policy Number:                         

Adjustor:                                                   

Adjustor’s Phone Number:                               

Automobile Liability Insurer’s Address:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Limits of Coverage:                                                                                                                   

Settlement Offers:                                                                                                                     

Claim Number:                                                                  

Party’s Employer, Address, and Telephone Number if Known:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Was this Party working at the time of the incident (__) Yes     (__)  No

Was this Party at fault, and if so, please state how he/she was at fault:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Was this Party injured, and if so, please describe the extent of their injuries:

                                                                                                                                               

                                                                                                                                               

INCIDENT

 Date of Incident:                           Time of Incident:                         

Location of Incident:                                                                                                                 

Make, Model, and Year of Automobile you were in at time of accident:

                                                                                                                                               

Name, Address, and Telephone Number of Owner of Automobile you were in at time of Accident:

                                                                                                                                               

                                                                                                                                               

Description of Scene

                                                                                                                                               

                                                                                                                                               

Weather Conditions at Time of Incident:

                                                                                                                                               

                                                                                                                                               

Drugs or Alcohol Involved:

                                                                                                                                               

Pictures of Scene:                                                                                                                      

The Speed of your Car at the Time of the Accident:                                                                

Were You Wearing Your Seat Belt at the Time of the Accident?(yes/no):

                                                                                                                                               

Which of the Occupants in Your Vehicle were Wearing Their Seat Belts?:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

The Speed of the Defendant’s Car at the Time of the Accident:                                              

Were you working at the time of the incident?  If so, please describe what you were doing and who you were working for.

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Where had you been for the six hours preceding the accident?  (Please list each location.)

                                                                                                                                           

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Do you know where any of the drivers had been prior to the time the accident occurred?  If so, please state where said drivers had been.

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                              

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

If you were working at time of incident, please provide the following information:

a.         Name of Worker’s Compensation Insurer:                                                        

b.         Address of Worker’s Compensation Insurer:

                                                                                                                           

                                                                                                                           

c.         Name of Adjustor:                                                                                             

d.         Telephone Number of Worker’s Compensation Insurer:                                   

e.         Worker’s Compensation Insurer Claim Numbers:                                             

Have you filed a claim for Worker’s Compensation Benefits and/or Medical Coverage?       If so please describe benefits applied for:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Description of Incident:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

How long before Medical Treatment Sought?

                                                                                                                                               

Were you taken to the Hospital by an Ambulance?

                                                                                                                                               

Please Draw a Diagram showing the scene of the accident and how it occurred below:

PASSENGERS

 Please give the information requested below for all of the passengers in the automobile you occupied at the time of the collision.

1. PASSENGER NUMBER ONE:

Name:                                                                                                                                     

Address:

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                        

Description of Passenger:                                                                                                          

Relationship to Client:                                                                                                               

2. PASSENGER NUMBER TWO:

Name:                                                                                                                                 

Address:

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                    

Description of Passenger:                                                                                                          

Relationship to Client:                                                                                                               

3. PASSENGER NUMBER THREE:

Name:                                                                                                                                 

Address

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                        

Description of Passenger:                                                                                                          

Relationship to Client:                                                                                                               

4. OTHER PASSENGERS:

Please give the information requested below for all of the passengers in the automobile driven by the Defendant at the time of the collision.

1. PASSENGER NUMBER ONE:

Name:                                                                                                                                

Address:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                       

Description of Passenger:                                                                                                          

Relationship to Defendant:                                                                                                        

2. PASSENGER NUMBER TWO:

Name:                                                                                                                                 

Address:

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                      

Description of Passenger:                                                                                                          

Relationship to Defendant:                                                                                                        

3. PASSENGER NUMBER THREE:

Name:                                                                                                                                 

Address

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                       

Description of Passenger:                                                                                                          

Relationship to Defendant:                                                                                                        

4.  OTHER PASSENGERS:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

 WITNESSES

 1. WITNESS NUMBER ONE:

Name:                                                                                                                                     

Address:

                                                                                                                                                   

                                                                                                                                                   

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                        

Description of Witness:                                                                                                             

Relationship to Client:                                                                                                               

2. WITNESS NUMBER TWO:

Name:                                                                                                                                 

Address:

                                                                                                                                              

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                      

Description of Witness:                                                                                                             

Relationship to Client:                                                                                                               

3.  WITNESS NUMBER THREE:

Name:                                                                                                                                

Address:

                                                                                                                                               

                                                                                                                                               

Telephone No.’s:(home)                       (work)                      (other)                     

Statements:                                                                                                                        

Description of Witness:                                                                                                             

Relationship to Client:                                                                                                               

4. OTHER WITNESSES:

_________________________________________________

 POLICE REPORTS

 Name of Officer:                                                                                                                   

Name of Law Enforcement Agency:                                                                                         

Police Report Taken:  (__) Yes    (__)  No           Copy:  (__) Yes   (__)  No

Police Report Number:                                                                                                              

Conclusions:                                                                                                                           

Citations:                                                                                                                                

Persons Who Made Statements to You or to Police and Contents of Same:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

 INJURIES

 Description of Injuries:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Pictures of Injuries (please attach):  (__) Yes   (__)  No

 MEDICAL HISTORY

 Unrelated Medical Conditions (describe condition and cause of problem):

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Past Injuries (describe condition and cause of problem):

                                                                                                                             

                                                                                                                            

                                                                                                                           

                                                                                                                       

                                                                                                                         

                                                                                                                     

Current Disability Caused by the above Conditions or Disabilities:

                                                                                                                       

                                                                                                                       

                                                                                                                           

Have you ever suffered any type of back injury (__) Yes     (__) No

If yes, please state how many times your back has been injured, the dates of said injuries, how your back was injured each time, what treatment you have received for your back, and the condition your back was in before your recent accident:

                                                                                                                              

                                                                                                                               

                                                                                                                              

                                                                                                                              

                                                                                                                                

                                                                                                                               

                                                                                                                             

                                                                                                                              

 MEDICAL TREATMENT FOR CURRENT INJURIES

 PHYSICIANS:

1. Name:                                                                                                            

Medical Specialty:                                                                                                                     

Medical Group:                                                                                                                          

Address:                                                                                                                  

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Description of Treatment:                                                                                                          

Diagnosis:                                                                                                              

Prognosis:                                                                                                            

Medications:                                                                                                       

Records:                                                                                                               

Amount of Bills:                                                                                                  

If Released from Care, When and Why:                                                                                   

2. Name:                                                                                                                

Medical Specialty:                                                                                                                     

Medical Group:                                                                                                                          

Address:                                                                                                                

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Description of Treatment:                                                                                                          

Diagnosis:                                                                                                             

Prognosis:                                                                                                           

Medications:                                                                                                        

Records:                                                                                                                

Amount of Bills:                                                                                                  

If Released from Care, When and Why:                                                                       ________________            

                                                                                                                                   

3. Name:                                                                                                                

Medical Specialty:                                                                                                                     

Medical Group:                                                                                                     

Address:                                                                                                                  

                                                                                                                                      

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Description of Treatment:                                                                                                          

Diagnosis:                                                                                                               

Prognosis:                                                                                                               

Medications:                                                                                                          

Records:                                                                                                                   

Amount of Bills:                                                                                                    

If Released from Care, When and Why:                                                                                   

HOSPITALS:

1. Name:                                                                                                                   

Address:                                                                                                                    

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Records:                                                                                                                   

Amount of Bills:                                                                                                    

2. Name:                                                                                                                   

Address:                                                                                                                

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Records:                                                                                                                   

Amount of Bills:                                                                                                    

PHYSICAL THERAPY:

1. Name:                                                                                                                    

Address:                                                                                                                   

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Records:                                                                                                                  

Amount of Bills:                                                                                                   

AMBULANCE SERVICE:

Name:                                                                                                                   

Address:                                                                                                                

Telephone Numbers:                                                                                                                  

Dates of Treatment:                                                                                                                   

Records:                                                                                                                  

Amount of Bills:                                                                                                     

PHARMACY:

1. Name:                                                                                                                     

Address:                                                                                                                      

Telephone Numbers:                                                                                                                  

Records:                                                                                                                    

Amount of Bills:                                                                                                      

2. Name:                                                                                                                    

Address:                                                                                                              

Telephone Numbers:                                                                                                                  

Records:                                                                                                                      

Amount of Bills:                                                                                                        

 SUBROGATION LIENS

 1. Name of Lienholder:                                                                                                              

Amount of Lien:                                                                                                         

Nature of Lien:                                                                                                             

2. Name of Lienholder:                                                                                                              

Amount of Lien:                                                                                                         

Nature of Lien:                                                                                                     

 HEALTH INSURANCE

 Name and Address of Your Health Insurance Company:

                                                                                                                                           

                                                                                                                                          

                                                                                                                                         

                                                                                                                                         

                                                                                                                                           

Group Policy Number:                                                                                                               

Contract Policy Number:                                                                                                           

Amount of Deductible or Copay:                                                                                              

Amounts Paid by Health Insurance to Date:                                

Amounts Paid by You to Date:                            

Names of Adjustors if Known:                                                                                                 

Telephone Numbers to Contact Health Insurance Company:                                                   

 PROPERTY DAMAGE

 Make, Model, Year, and Approximate Mileage of Your Vehicle:                                            

Description of Damage:                                                                                                             

Estimates:                                                                                                                      

Do You Have Pictures of the Automobile Occupied by You:                                                  

Name and Address of Wrecker Service and Cost of Same:

                                                                                                                                       

                                                                                                                                      

Out of Pocket Expenses Related to Repairs to the Vehicle and Loss of Use of the vehicle (Please describe these expenses):

                                                                                                                                    

                                                                                                                                    

                                                                                                                                     

Payments by Your Insurer:                                                                                                        

Payments by Defendant’s Insurer:                                                                                            

Number of days without use of Automobile:                                                                            

Rental Car Expenses and Name of Rental Company:                                                               

Name, Address, Telephone Number, and Cost of Wrecker Service Used for Your Automobile:

                                                                                                                                    

                                                                                                                                  

                                                                                                                                  

Current Location of Automobile You Occupied (Give Address and Phone Numbers if Applicable):

                                                                                                                                  

                                                                                                                                 

                                                                                                                                

Name and Address of Body Shop Responsible for Repairs to Automobile Occupied by You:

                                                                                                                              

                                                                                                                             

                                                                                                                           

Condition of Defendant’s Automobile:                                                                                    

Do You Have Pictures of the Defendant’s Automobile:                                                          

Current Location of Defendant’s Automobile:

                                                                                                                               

                                                                                                                              

YOUR DRIVING RECORD

 List all Traffic Citations you have received in the past ten years:

1. Approximate Date of Citation:              Location of Citation:                            

Name of Law Enforcement Agency Issuing Said Citation:                                          

Reason Stated for Receiving Citation:                                                                          

Were You Found Guilty: (__) Yes    (__)  No

If yes, what was Your Punishment and/or Fine:                                                           

2. Approximate Date of Citation:              Location of Citation:                            

Name of Law Enforcement Agency Issuing Said Citation:                                          

Reason Stated for Receiving Citation:                                                                          

Were You Found Guilty: (__) Yes    (__)  No

If yes, what was Your Punishment and/or Fine:                                                           

3. Approximate Date of Citation:              Location of Citation:                            

Name of Law Enforcement Agency Issuing Said Citation:                                          

Reason Stated for Receiving Citation:                                                                          

Were You Found Guilty: (__) Yes    (__)  No

If yes, what was Your Punishment and/or Fine:                                                           

4. Approximate Date of Citation:              Location of Citation:                            

Name of Law Enforcement Agency Issuing Said Citation:                                          

Reason Stated for Receiving Citation:                                                                          

Were You Found Guilty: (__) Yes    (__)  No

If yes, what was Your Punishment and/or Fine:                                                           

5. Approximate Date of Citation:              Location of Citation:                            

Name of Law Enforcement Agency Issuing Said Citation:                                          

Reason Stated for Receiving Citation:                                                                          

Were You Found Guilty: (__) Yes     (__) No

If yes, what was Your Punishment and/or Fine:                                                           

List all Motor Vehicle Accidents that You have been Involved in as a Driver during Your entire Life:

1. Approximate Date of Accident:               Location of Accident:                        

Who was at Fault:                                                                                                          

How was this Accident Resolved (i.e.: Was it settled? Was there a lawsuit? How much money     was it settled for?)

                                                                                                                  

2. Approximate Date of Accident:               Location of Accident:                        

Who was at Fault:                                                                                  

How was this Accident Resolved (i.e.: Was it settled? Was there a lawsuit? How much money     was it settled for?)

                                                                                                                   

3. Approximate Date of Accident:               Location of Accident:                        

Who was at Fault:                                                                                    

How was this Accident Resolved (i.e.: Was it settled? Was there a lawsuit? How much money     was it settled for?)

                                                                                                                        

Has Your Drivers License ever been Suspended? If so, please explain the reasons why:

                                                                                                                                    

                                                                                                                                   

                                                                                                                          

                                                                                                                             

EMPLOYMENT

 1. Employer’s Names:                                                                                                                

Addresses:                                                                                                   

                                                                                                                   

Telephone Numbers:                                                                                                                  

Name and Job Title of Immediate Supervisor:                                                                          

Rate of Pay:                                                                                                 

Time Missed from Work Due to Injury:                                                                                    

Lost Wages:                                                          

Date Returned to Work:                                       

Do you have last year’s W-2 Forms. If so, please provide:                                                       

Do you have a recent earnings statement.  If so, please provide:                                              

Please provide a written statement from your employer stating the number of days you missed from work, the number of hours you missed from work during that period, your average rate of pay, and the amount of money you would have made during that time period. If you have provided this document, please indicate that you have provided it by writing “yes” below:

Dates of Employment with Employer:                                                                                      

2. Employer’s Names:                                                                                                                

Addresses:                                                                                          

Telephone Numbers:                                                                                                                  

Name and Job Title of Immediate Supervisor:                                                                          

Rate of Pay:                                                                                                  

Time Missed from Work Due to Injury:                                                                                    

Lost Wages:                                                          

Date Returned to Work:                                                                                                            

Do you have last year’s W-2 Forms.  If so, please provide:                                                      

Do you have a recent earnings statement.  If so, please provide:                                              

Please provide a written statement from your employer stating the number of days you missed from work, the number of hours you missed from work during that period, your average rate of pay, and the amount of money you would have made during that time period.  If you have provided this document, please indicate that you have provided it by writing “yes” below:

Dates of Employment with Employer:                                                                                      

 OTHER SOURCES OF INCOME

 Investments (give annual amount):                                                                                            

Social Security Disability or Retirement Benefits (give annual amount):                                 

Worker’s Compensation Benefits (give annual amount):                                                          

Disability Insurance Benefits (give annual amount):                                                                 

Other (give source of income and annual amount):                                                                   

 CHARACTER WITNESSES

 At the trial of your case we may need to call a witness to testify about the pain that you have been in.  It is best to have a person who is fairly influential in the community, who knows you fairly well, and who can verify that they have seen you on several occasions since the accident.  I prefer to call your employer, your religious leader, your teacher, or anyone who is well known and respected in your community.  Therefore, please list three such people below giving their name, address, phone number, position in the community, and how you know them.

1.         Character Witness Number One:

Name:                                                                                                                         

Address:                                                                                                                

Phone Number:                                                                                                                          

Position:                                                                                                                      

How you know him/her:                                                                                                            

2.         Character Witness Number Two:

Name:                                                                                                                         

Address:                                                                                                               

Phone Number:                                                                                                                          

Position:                                                                                                                     

How you know him/her:                                                                                                            

3.         Character Witness Number Three:

Name:                                                                                                                          

Address:                                                                                                                    

Phone Number:                                                                                                                          

Position:                                                                                                                      

How you know him/her:                                                                                                            

How you know him/her:                                                                                                            

 HOBBIES & ACTIVITIES

 Please list and describe each of the hobbies and activities that you are regularly engage in. Include hunting, fishing, playing sports, doing yard work, going to church, charitable work, and any other activity you are involved in outside of your employment. If you are involved with an organization, please give its name, phone number, and person who is in charge of running the organization.

                                                                                                                                          

                                                                                                                                         

                                                                                                                                           

 OTHER INFORMATION

 Prior Lawsuits:(give date, injuries, circumstances, and resolution)

                                                                                                                                           

                                                                                                                                          

Prior Convictions (give dates, sentence, and current status):

                                                                                                                                          

                                                                                                                                           

Drinking Habits:                                                                                                          

Smoking Habits:                                                                                                        

Settlement Offers:                                                                                                                     

Referred By:                                                                                                                              

Other Attorneys Consulted:                                                                                                      

Please give any other information about yourself you believe may be important.  If there is anything about yourself or your past that may have a negative impact on what a jury thinks about your condition or your character, you need to reveal this information below.  During the course of your case this information will most likely be revealed if you don’t disclose it to me now.  By disclosing this  information to me now, I can prepare your case so that this information is not revealed or has the least impact possible.  This information may relate to, prior accidents you have been involved in, prior alcohol problems, prior drug problems, prior legal problems, prior medical treatment, prior employment problems, your current and/or former occupations,  and/or anything about yourself that  may negatively impact a jury’s opinion of you and/or your case.  Although this information may be somewhat embarrassing to you, your informing me about this information now is very important to the outcome of your case.  I promise that I will not voluntary reveal any of this information to anyone without your knowledge and consent.

 DOCUMENTS NEEDED

I need the originals of the following documents if you have them.  Please include these documents when you return this questionnaire if you have them.  If you do not have them, you are in the process of getting them, or they are not available yet, please state where they are, when they will be ready, and how I can get them.

Have you provided the following:

1. Police or accident report:                                                                                                       

2. All of your medical records (If you are still being treated, please describe what you have provided, and when you anticipate being released from medical treatment.):                                                                  

                                                                                                                                                   

                                                                                                                                                   

3. All of your medical bills (If you are still being treated, please describe what you have provided, and when you anticipate being released from medical treatment.):

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

4. Recent payment stubs:                                                                                                           

5. The past four years Income Tax Returns:                                                                              

6. The past four years W-2’s:                                                                                                     

7. Damage or loss estimates for the property damage to your automobile:

                                                                                                                                                   

                                                                                                                                                   

8. Receipts or bills for the repairs to your automobile:                                                              

9. Pictures of your injuries:                                                                                                        

10. Pictures of the scene of the accident:                                                                                  

11. Letters from insurance companies regarding this matter:                                                    

12. A copy of all of your automobile insurance policies:                                                           

13. Copies of all rental car agreements and bills:                                                                       

14. A copy of your driver’s license:                                                                                           

15. A written statement from your employer stating the number of days you missed from work, the number of hours you missed from work during that period, your average rate of pay, and the amount of money you would have made during that time period.

                                                                                                                                                   

                                                                                                                                                   

16. New Articles about the accident:                                                                                        

17. Any other documents or other materials (Please describe any other documents or other materials which you have either provided or which you believe exist and may be helpful to your case.  Also, explain how you believe this document or other material may be helpful to your case. Other materials may include pictures or pieces of physical evidence such as bumpers, tires, seat belts, other parts of your car, neck braces, crutches, casts, or anything else which tends to show either liability or your damages. ):

                                                                                                                                                   

                                                                                                                                                   

 CLIENT EXPECTATIONS

 Describe your expectations for the outcome of your case:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

What amount of money do you expect to recover for yourself after all legal fees have been paid:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

Please describe all circumstances which you believe support your recovery of this amount:

CLIENT COMMENTS

             I hereby declare that that I have completed this questionnaire to the best of my ability and knowledge.

Date:                                                                                                                                         

SIGNATURE

 EVALUATION

(For Attorney’s Use Only)

 Total Medical Bills: ________________________________

Lost Wages: _____________________________________

Other Financial Losses: ____________________________

Extent of Injuries: ________________________________

Liability: _______________________________________

Available Insurance Coverage: ______________________

Valuation: ______________________________________

Type of Representation and Attorney Compensation:

_______________________________________________

Comments: ______________________________________

_______________________________________________

Attorney Specific Forms

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/


Inside Client Questionnaire