Injury Claim Coach Guide

PREMISES LIABILITY ACCIDENT PERSONAL INJURY CLIENT QUESTIONNAIRE

Person Filling Out This Report Date

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

Name

Address

Telephone No.'s (home) (work) (other)

Social Security Number Date of Birth

Height Weight Age Race

Marital Status

Name of Spouse, if any

Social Security Number Age

Children

Name Age

Name Age

Name Age

Name Age

PREMISES INFORMATION

Name of Establishment

Address

Manager

Employees Having Knowledge About Incident

Name

Address

Phone number

Name

Address

Phone number

Name

Address

Phone number

Name

Address

Phone number

Property and Casualty Insurer

Name of Insurer

Insurer’s Address

Policy Number Limits of Coverage $

Adjustor

Insurer’s Phone Numbers

Settlement Offers $

Claim Number

INCIDENT

Date of Incident Time of Incident

Location of Incident

Description of Scene

Weather Conditions at Time of Incident

Drugs or Alcohol Involved Yes No

Pictures of Scene Yes No

Please Describe in Detail What Happened

WITNESSES

Name

Address

Telephone Numbers (home) (work) (other)

Statements

Description of Witness

Relationship to Client

Other Information about Witness

Name

Address

Telephone Numbers (home) (work) (other)

Statements

Description of Witness

Relationship to Client

Other Information about Witness

Name

Address

Telephone Numbers (home) (work) (other)

Statements

INJURIES

Description of Injuries

Pictures of Injuries Yes No

Preexisting Injuries

MEDICAL TREATMENT

Physicians

Name

Medical Group

Address

Telephone Numbers

Dates of Treatment

Description of Treatment

Diagnosis

Prognosis

Medications

Records

Amount of Bills $

If Released from Care, When Why

Name

Medical Group

Address

Telephone Numbers

Dates of Treatment

Description of Treatment

Diagnosis

Prognosis

Medications

Records

Amount of Bills $

If Released from Care, When Why

SUBROGATION LIENS

Name of Lienholder

Amount of Lien $

Nature of Lien

Name of Lienholder

Amount of Lien $

Nature of Lien

EMPLOYMENT

Employers’ Names

Addresses

Telephone Numbers

Name and Job Title of Immediate Supervisor

Rate of Pay $ per

Time Missed from Work Due to Injury

Lost Wages $

Date Returned to Work

Have You Filed Tax Returns for the Past Two Years Yes No

HEALTH INSURANCE

Name of Your Health Insurance Company

Address

Amount of Deductible or Co-pay $

Amounts Paid by Health Insurance to Date $

Amounts Paid by You to Date $

Names of Adjustors if Known

Telephone Number of Health Insurance Company

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 Yes No Name

Miscellaneous

CLIENT COMMENTS

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?

Incident or accident report Yes No

All of your medical records Yes No

All of your medical bills Yes No

Recent payment stubs Yes No

The past four years Income Tax Returns Yes No

The past four years W-2's Yes No

Pictures of your injuries Yes No

Pictures of the scene of the accident if you have any Yes No

Letters from insurance companies regarding this matter Yes No

Any other documents or other materials Yes No

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 which tend to show either liability or your damages.

CLIENT EXPECTATIONS

Describe your expectations for the outcome of your case

EVALUATION

(For Attorney’s Use Only)

Total Medical Bills $

Extent of Injuries

Liability

Available Insurance Coverage

Valuation $

Type of Representation and Attorney Compensation

Comments