Personal Injury Case Intake Form

Personal Information

First Name

Last Name

Date of Birth

Socila Seucrity No. (last 4 digits)

Current US Address

City

State

Zip

Phone Number

Accident Information

Date of Accident

Time of Accident

Location of accident

Type of accident

Weather Condition at at accident time

Details description of accident

Were there any witnesses?

Injury Information

Description of Injury

Did you seek immediate medical attention?

List all medical providers seen

Ongoing symptoms

Pre-existing conditions

Insurance & Claims Information

Your Insurance Company

Policy Number

Other Party's Insurance (if known)

Claim Number (if assigned)

Have you been contacted by any insurance companies?

If yes, do not provide statement until speaking with your attorney

Have you signed and documents?

If yes, please provide copies of all signed documents

Damages Information

Have you missed work due to your injuries?

First Day Missed

Return to work Date (if applicable)

List of out-of-pocket expenses (Include medical bills, prescription, trasnportation cost etc.

Evidence Checklist (if applicable)
Please bring the following items to the consultation

PRIVACY NOTICE: The information provided in this form is protected by attorney-client privilege and will be used solely for the purpose of evaluating your immigration case.

ACCURACY STATEMENT: I certify that the information provided is true and correct to the best of my knowledge. I understand that providing false information may affect the handling of mu case.

NO GUARANTEE: Completion of this intake form does not guarantee representation or specific results in your case. Our attorneys will evaluate your case and discuss potential outcomes during your consultation.

Personal Injury Case Intake Form

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Contact Information

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