Paternity Intake Form

Personal Injury Intake Sheet

PERSONAL INFORMATION:

Client's Name Aliases Date

Address

Phones (H) (W)

SSN Race: Sex: Age:

DOB:

Married? M S D Resides With: Phone

Education: Elem H.S. Grade Diploma? College

Trade School

Spouse's Name: Phones (H) (W)

Address

Employer

Children:

Name DOB Age

Name DOB Age

Father's Name: Phones(H) (W) [ ]L [ ]D Employer

Mother's Name: Phones(H) (W) [ ]L [ ]D Employer

If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and relationships to decedent of the decedent's immediate family:

Name: Address: Telephone: Relation:

Name: Address: Telephone: Relation:

EMPLOYMENT INFORMATION:

Name of employer (if unemployed, last employer): Address of employer: Telephone number:

Personnel Director/Supervisor:

Job title/type of work:

Present rate of pay: $ (per week/month/year) Hours worked each week:

Do you regularly work overtime? If so, indicate approximate amount of time & rate of pay:

Do you receive tips or other type of income? If so, indicate:

Type of income Amount $ per

Type of income Amount $ per

Type of income Amount $ per

When did you first begin working for this employer?

If unemployed, when did you leave this employer?

Reason for leaving:

What was your reported income in the year before your accident? $

Were you working for your employer at the time the injury occurred?

Have you applied for worker's compensation benefits as a result of your accident?

If so, indicate the amounts paid to or received by you to date: $

State your employment history for past ten years:

Name of employer:

Address:

Period of employment: From To

Position: Salary:

Reason for leaving:

POLICE RECORD:

Have you ever been convicted of a felony? If so, describe as follows:

1. Date of conviction: Place: Charge:

Result:

2. Date of conviction: Place: Charge:

Result:

Is there now, or has there ever been, a restriction on your driver's license?

If so, describe the details of such restriction:

CLAIMS AND LAWSUITS:

Have you ever been involved in any claim or lawsuit, excluding divorce?

If so, list below every claim you have made for money or lawsuits in which you have ever been involved:

Date: Place: Against whom:

Nature of claim:

Result:

INSURANCE INFORMATION:

Name of insurance company: Adjuster's name:

Street address: Telephone:

City, state, zip: Policy number:

Do you have insurance covering damage to your car? Deductible amount: $

How much does your insurance cover if you hurt someone else with your car? $

Uninsured motorist policy limits: Med Pay Amount $

Do you have a second uninsured motorist policy?

If so, fill in the following:

Name of second insurance company:

Address:

City, state, zip: Claim adjuster's name:

Telephone: Policy limits: $ Policy number:

Do you have health or accident insurance? If so, indicate:

Name of health insurance company:

Address:

Telephone: Policy #: Insurance agent's name:

Name of accident insurance company:

Address:

Telephone: Policy #: Insurance agent's name:

Have you ever had insurance of any kind declined or cancelled? If so, give reason:

EDUCATION:

Educational background, listing names of schools attended, addresses, years attended and any degrees obtained:

Name & address of school Years attended Degree

Name & address of school Years attended Degree

Name & address of school Years attended Degree

MEDICAL HISTORY BEFORE ACCIDENT

Have you been hospitalized at any time before this accident?

If so, list below all hospitalizations:

Have you had any physical examinations before this accident?

Have you had any accidents or injuries before this accident?

Have you had any chronic illnesses or diseases before this accident?

Have you had any other chronic health problems or disabilities?

Did you use any drugs or medication regularly before the accident?

Have you ever had any broken bones?

Date: Circumstances:

Date: Circumstances:

MILITARY BACKGROUND:

Were you in the military service? Dates: from to Type of discharge: Branch of service:

Any service-connected injuries? If so, describe details:

Have you received or do you receive payments from VA, social security or other source?

Claim number:

FACTS OF THE ACCIDENT:

Date: Day: Time:

Weather conditions:

Describe what happened:

DIAGRAM: Indicate on a diagram in the space below what happened. Write in street or highway names or numbers and show direction of travel by arrows. Also, show north by putting an arrow in a circle:

Show north:

Were seat belts in use in your vehicle? If so, who in your vehicle was using a seat belt and who was not using a seat belt:

Were police called to the scene of the accident? If so, did the police take photographs of the accident scene? If so, which police department has possession of such photographs?

FACTS CONCERNING THE DEFENDANT:

Name and address of person (defendant) responsible for accident:

Full name of defendant:

Street address:

City, state, zip:

Name of defendant's employer:

Name of defendant's spouse:

Name of defendant's insurance company:

Street address:

City, state, zip:

Adjuster's name: Phone

Do you know what the defendant's financial circumstances are without regard to any insurance he might have? If so, specify:

Give your observations about the defendant as a person:

Name of 2nd person responsible for accident:

Street address:

City, state, zip:

Name of 2nd person's insurance company:

Address: Claim no:

Adjuster's name: Policy no: Policy limits: $

Name of 3rd person responsible for accident:

Street address:

City, state, zip:

Name of 3rd person's insurance company:

Address: Claim no:

Adjuster's name: Policy no: Policy limits: $

OTHER INJURED PARTIES:

Were other parties, other than the defendant, injured in this accident?

Name of 2nd injured party: Street address: Telephone number:

City, state, zip: Birthdate: Relationship to you:

Name of 3rd injured party: Street address: Telephone number:

City, state, zip: Birthdate: Relationship to you:

WITNESSES TO THE ACCIDENT:

Name of 1st witness: Address: Telephone: Age:

Employment:

Nature of testimony:

Name of 2nd witness: Address: Telephone: Age:

Employment:

Nature of testimony:

Name of 3rd witness: Address: Telephone: Age:

Employment:

Nature of testimony:

STATEMENTS MADE:

Have you talked with any police officer, investigator, insurance adjuster or any other person about this incident?

If so, indicate to whom you have spoken, the person's address and telephone number:

Name Address Telephone

Have you given a written or recorded statement to any person about this incident?

Name of person to whom statement was given:

Date given: If written, do you have a copy?

Persons present at time:

Did you sign the statement?

Did the defendant make any statement to you or in your presence concerning this incident?

When and where was the above statement made?

List the names and addresses of any persons who may have heard it:

Name: Address:

Name: Address:

Were any statements about the accident made to or taken from anyone else at the scene of the accident?

DAMAGES FROM ACCIDENT:

State in full detail all injuries you received as a result of this accident:

State your present physical condition such as scars, deformities, headaches, etc.:

Describe "loss of enjoyment of life" by listing below what normal activities, including sports, hobbies or other activities, you enjoyed before this accident and cannot do now as a result of the accident:

Activity prior to accident Number of times/week Since accident Number of times/week

Activity prior to accident Number of times/week Since accident Number of times/week

Have you missed time from work as a result of your injuries?

If so, indicate the following: From To From To

Did you lose wages for the periods of time missed from work due to this accident? If so, state the total wages lost to date and the dates:

Wages lost: Dates:

Wages lost: Dates:

Have you had any increases or decreases in your pay since the accident?

Did you lose any promotion or merit increase or fringe benefits due to the accident?

If self employed, have you had to hire anyone to take your place?

If you are a student, indicate time lost from school:

Indicate period of time you were confined to your home:

Indicate period of time you were confined to bedrest:

When is it expected you can return to work?

List any non-monetary compensation you have lost:

Have you been forced to borrow any money as a result of your injuries and inability to work?

Are you able to work part time? If so, where or what kind of work could you do?

List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in this accident:

Name of hospital: Address: From: To: Total costs:

Name of hospital: Address: From: To: Total costs:

Name of hospital: Address: From: To: Total costs:

List the full name, address and telephone number of each physician who has examined or treated you for your injuries:

Doctor's name: Telephone:

Address:

Specialty:

Type of treatment:

Have you used any of the following in connection with treatment?

Wheelchair Dates: From To

Back or neck brace/collar Dates: From To

Crutches Dates: From To

Traction Dates: From To

Physical therapy Dates: From To

Other: Dates: From To

List all medications which you have taken for injuries, the name of the doctor prescribing each medication and length of time you took the medication:

Type of medication Prescribing doctor's name Length of time

Type of medication Prescribing doctor's name Length of time

Indicate the amount of all bills/expenses incurred to date as a result of this accident: $

Have you sustained any other injuries since this accident?

PROPERTY DAMAGE:

If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs:

Telephone number: Have you incurred car rental expenses? $

Where is your vehicle presently located?

If any other personal property was damaged, describe said property:

Total medical & related expenses to date: $ Date:

Total of property damage amount to date: $ Date:

IMPORTANT

Please collect and attach copies of all medical and related bills incurred to date as a result of this accident, indicating which have been paid and which are still due. Please be sure to forward copies of all future medical bills, drug/medication bills, etc., as they are incurred, even if paid by insurance. See the following two pages for list of items to provide to your attorney and a list of general instructions that will require your attention. In completing this intake sheet, have you thought of any information which I have not asked which may be of some assistance to me in representing you? If so, state it on the back of this form no matter how silly, trivial or embarrassing it may seem.

INSTRUCTIONS TO CLIENT

Please be sure to provide me with the following:

EMPLOYMENT CONTRACT AND POWER OF ATTORNEY IN A PERSONAL INJURY CASE

THIS AGREEMENT made this date at Jackson, Mississippi, by and between MARK T. FOWLER, Attorney at Law, hereinafter known as ATTORNEY and hereinafter known as CLIENT.

CLIENT retains ATTORNEY to represent him as his Attorney at Law in a cause of action against regarding the following facts, to-wit:

IN WITNESS WHEREOF, the parties have set their hands this the day of , .

MEDICAL AUTHORIZATION

TO WHOM IT MAY CONCERN:

I, the undersigned , hereby authorize any physician, hospital, nurse, chiropractor, dentist, psychologist, or other medical attendant to furnish full and complete medical reports, records, and other information herewith requested by , or to any representative, attorney or investigator from his firm.

The purpose of this authorization is to allow the above attorney to obtain all medical records which will aid in or are necessary for the prosecution of claims I am making.

This authorization includes the right to examine all x-rays and records of any kind, and the right to receive full and complete information pertaining thereto, including copies of all such records.

This authorization is intended to and will allow the above attorney to obtain any and all medical records, and shall include any and all records prior to or subsequent to the date of the claim referred to above.

Your full cooperation with my attorney is requested. You are further requested to disclose no information nor discuss my medical condition with any insurance adjuster or other person without my written authority to do so.

This authority shall be valid until cancelled or revoked by me in writing.

A photostatic copy of this authorization shall be considered as effective and as valid as the original.

ALL PRIOR AUTHORIZATION IS HEREBY CANCELLED

FORM 4506 REQUEST FOR COPY OF TAX FORM OR INDIVIDUAL INCOME TAX ACCOUNT INFORMATION

1. Name of taxpayer as shown on tax form:

2. Current name and address:

3. If information is to be mailed to someone else, show the third party's name and address:

4. If name in third party's records differs from item 1 above, show here:

5. Social security or employer identification number as shown on tax form:

6. Spouse's social security number as shown on tax form: Spouse's name:

7. Tax form number (Form 1041, 941, etc.):

8. Tax period(s) (No more than 4 per request):

9. Amount due (Make check payable to IRS): $

10. Describe what you want (Check only one box):

$5.00 each Copy of tax return and all attachments (including forms w-2) Certified for court or administrative proceedings

$2.50 each Tax account information only (do not use for income averaging)

$2.50 each Form 1040a or form 1040ez verification only

DATE: Signature:

Telephone:

OUT OF POCKET EXPENSES

Client:

DOCTOR BILLS

TOTAL DOCTOR BILLS $

DRUGS

TOTAL DRUG BILLS $

HOSPITAL

TOTAL HOSPITAL BILLS $

PROPERTY DAMAGE

TOTAL PROPERTY LOSS $

EARNINGS LOSS

TOTAL EARNINGS LOSS $

OTHER LOSS

TOTAL OTHER LOSS $

TOTAL OUT OF POCKET LOSS $