Fill and Sign the Injury Questionnaire Form

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 - 1 - 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 - 2 - 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 - 3 - 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 - 4 - ) Statements Description of Witness Relationship to Client Other Information about Witness OTHER WITNESSES (Please give as much information about these people as possible) INJURIES Description of Injuries Pictures of Injuries Yes No Preexisting Injuries - 5 - 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 - 6 - 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 - 7 - Amount of Bills $ If Released from Care, When Why Hospitals Name Address Telephone Numbers Records Amount of Bills $ Name Address Telephone Numbers Records Amount of Bills $ Physical Therapist Name Address Telephone Numbers Records Amount of Bills $ SUBROGATION LIENS Name of Lienholder Amount of Lien $ - 8 - 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) - 9 - 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 (If you are still being treated, please describe what you have provided, and when you anticipate being released from treatment.) - 10 - All of your medical bills Yes No (If you are still being treated, please describe what you have provided, and when you anticipate being released from treatment.) 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 How much money do you expect to recover after payment of legal fees? $ Please describe all circumstances which you believe support your recovery of this amount - 11 - EVALUATION (For Attorney’s Use Only) Total Medical Bills $ Extent of Injuries Liability Available Insurance Coverage Valuation $ Type of Representation and Attorney Compensation Comments - 12 -