Scarborough Personal Injury Lawyer - Mendel Personal Injury Lawyer (905) 581-0227.
Personal Injury Intake Form
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Transcript of Personal Injury Intake Form
PERSONAL INJURY INTAKE FORM
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—CONFIDENTIAL—
DEAR CLIENT, YOU HAVE MADE A WISE DECISION TO ASSIGN YOUR CASE TO OUR LAW FIRM. ALL
THE INFORMATION YOU PROVIDE HERE IS VITAL TO ASSESS YOUR CASE AND HELPFUL TO CLAIM FOR
MAXIMUM COMPENSATION. PLEASE PRINT THIS WORKSHEET AND PROVIDE THE INFORMATION
BELOW. IF YOU DO NOT KNOW THE ANSWER TO A QUESTION LEAVE IT BLANK.
DATE: ATTORNEY NAME: CASE FILE NO:
CLIENT INFORMATION
1. PERSONAL INFORMATION
NAME: ___________________________________________________________________________
ADDRESS:__________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________
HOME PHONE: _____________________ WORK PHONE: ____________________ __________
FAX NUMBER: _____________________ E-MAIL: ___________________________________
DATE OF BIRTH:____________________ SOCIAL SEC. NO.: ___________________________
NATIONALITY: _____________________ CELL PHONE: _______________________________
BEST TIME TO CONTACT: _____________________________________________________________
ARE YOU AN EXISTING CLIENT? YES [ ] NO [ ]
HOW DID YOU HEAR ABOUT US: GOOGLE [ ] CLIENT REFERRAL [ ] ATTORNEY REFERRAL [ ]
NAME OF THE CLIENT OR ATTORNEY WHO REFEERRED YOU:_______________________________
PREFERRED LANGUAGE: ENGLISH [ ] SPANISH [ ]
MARITAL STATUS: SINGLE [ ] MARRIED [ ] DIVORCED [ ]
IF MARRIED PROVIDE AN INFORMTION AS BELOW
SPOUSE NAME: ___________________________________________________________________
ADDRESS: ________________________________________________________________________
_________________________________________________________________________________
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HOME PHONE: _____________________ WORK PHONE: ____________________ _________
FAX NUMBER: _____________________ E-MAIL: ___________________________________
DATE OF BIRTH:____________________ SOCIAL SEC. NO.: ___________________________
NATIONALITY: _____________________ CELL PHONE: _______________________________
OCCUPATION _____________________________________________________________________
SPOUSEC EMPLOYER AND ADDRESS_____________________________________________________
_________________________________________________________________________________
CHILDREN NAME, AGE AND EDUCATION:
1. __________________________________________
2. __________________________________________
OTHER DEPENDENTS NAME, AGE, RELATIONSHIP, AND LOCATION:
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
2. INFORMATION ON THE CLIENT EDUCATION
EDUCATION: ____________________________________________________________________
YEAR OF COMPLETION: ____________________________________________________________
3. INFORMATION ON THE CLIENT EMPLOYMENT
EMPLOYEE [ ] SELF EMPLOED [ ] OWNS A BUSINESS [ ] UNEMPLOYED [ ]
NAME OF EMPLOYER:________________________________________________________________
POSITION:________________________________________________________________________
HOW LONG YOU WERE EMPLOYED WITH THIS EMPLOYER?______________________________ ___
MONTLY INCOME:___________________________________________________________________
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EMPLOYMENT ADDRESS:_____________________________________________________________
_________________________________________________________________________________
TELEPHONE:__________________________________ FAX NO.:____________________________
SUPERVISOR NAME AND TELEPHONE NO.:_______________________________________________
DATES OF WORK MISSED:_____________________________________________________________
TOTAL LOST WAGES: _______________________________________________________________
4. INFORMATION ON BUSINESS:
DO YOU OWN A BUSINESS? YES [ ] NO [ ]
BUSINESS NAME :___________________________________________________________________
BUSINESS LOCATION:________________________________________________________________
_________________________________________________________________________________
MONTHLY BUSINESS INCOME: ________________________________________________________
5. INFORMATION ON ANY OTHER ATTORNEYS YOU HAVE CONTACTED REGARDING THIS MATTER:
ATTORNEY NAME AND LOCATION:________________________________________________
CONTACT DATE: _________________________________________________________________
6. INFORMATION ON MILITARY SERVICE:
HAVE YOU BEEN IN THE MILITARY SERVICE? YES [ ] NO [ ]
IF SO,ANSWER THE QUESTIONS BELOW:
SERVICE NUMBER:__________________________________________________________________
TYPE OF DISCHARGE:________________________________________________________________
DATES OF SERVICE:__________________________________________________________________
INFORMATION ON ANY SERVICE CONNECTED INJURIES OR DISABILITY IF ANY:___________________
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__________________________________________________________________________________
PERCENTAGE OF DISABILITY:___________________________________________________________
PRESENT CONDITION OF SERVICE CONNECTED INJURY OR DISABILITY: _________________________
__________________________________________________________________________________
DO YOU RECEIVE PAYMENTS FOR SERVICE CONNECTED INJURIES? YES [ ] NO [ ]
IF SO, DETAILS______________________________________________________________________
7. INFORMATION ON PRIOR CLAIMS AND LAW SUITS
DO YOU HAVE ANY PRIOR CLAIMS OR LAW SUITS ? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
DATE: ____________________ NATURE OF CLAIM: ____________________
YOUR OPPONENT DETAILS: __________________________________________________________
RESULT: ___________________________________________________________________________
6. PRIOR POLICE RECORD
DO YOU HAVE ANY PRIOR CRIMINAL BACKGROUND? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
PROVIDE DETAILS ON THE DATE, PLACE, COURT NAME, TYPE OF CHARGE AND OUTCOME: ________
__________________________________________________________________________________
8. PRIOR DISABILITY CLAIMS
DID YOU HAVE ANY DISABILITY CLAIMS? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
INFORMATION ON THE WORKERS COMPENSATION CLAIM:_________________________________
DATE OF INJURY:___________________________________________________________________
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DETAILS ON PAYMENTS IF ANY:________________________________________________________
__________________________________________________________________________________
INFORMATION ON ANY OTHER DISABILITY PAYMENTS:_____________________________________
__________________________________________________________________________________
9. PRIOR PHYSICAL EXAMINATIONS
DID YOU HAVE PHYSICAL EXAMINATION FOR ANY PURPOSE DURING THE LAST FIVE YEAR? YES [ ]
NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
DATE:_______________________________ PLACE________________________________________
NAME OFDOCTOR __________________________________________________________________
PURPOSE_________________________________________________________________________
( employment, promotion, insurance, selective service, armed forces, etc)
10. PRIOR ACCIDENT AND INJURIES
DID YOU HAVE ANY PRIOR ACCIDENTS OR INJURIES ? YES [ ] NO [ ]
IF SO, PROVIDE INFORMATION ON THE DATE, PLACE, NATURE OF THE ACCIDENT ________________
__________________________________________________________________________________
__________________________________________________________________________________
11. ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE
HAVE YOU EVER BEEN TREATED FOR ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE? YES [
] NO [ ]
IF SO, PROVIDE THE DETAILS:__________________________________________________________
__________________________________________________________________________________
12. PRIOR ILLNESS OR DISEASE
DID YOU HAVE ANY PRIOR ILLNESS OR DISEASE? YES [ ] NO [ ]
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IF SO, PROVIDE THE DETAILS
DATE___________________ NATURE OF ILLNESS:_________________________________________
DURATION:________________ TREATED BY:____________________________________________
NAME AND ADDRESS OF THE HOSPITAL:_________________________________________________
__________________________________________________________________________________
13. TROUBLE WITH EYES OR EARS
DO YOU NOW, OR HAVE YOU EVER HAD TROUBLE WITH EYES OR EARS: YES [ ] NO [ ]
IF SO, PROVIDE THE DETAILS
__________________________________________________________________________________
__________________________________________________________________________________
14. RADIOACTIVE SUBSTANCES AND ASBESTOS
HAVE YOU EVER WORKED WITH RADIOACTIVE SUBSTANCES OR ANY OTHER SUSTANCE ALLEGED TO
CAUSE ANY DISEASES? YES [ ] NO [ ]
15. INFORMATION ON HEALTH INSURANCE DENIAL
HAVE YOU EVER BEEN DENIED OF HEALTH INSURANCE? YES [ ] NO [ ]
IF SO, BY WHICH COMPANY AND REASON FOR DENIAL:_____________________________________
_________________________________________________________________________________
16. INFORMATION ON ACCIDENT
DATE OF ACCIDENT: _________________________________________________________________
LOCATION OF ACCIDENT:____________________________________________________________
NAMES OF OTHER PEOPLE INVOLVED IN THE ACCIDENT/INJURY, THEIR ADDRESS AND TELEPHONE
NUMBER:
1. ___________________________________________________________________________
__________________________________________________________________________
2. __________________________________________________________________________
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__________________________________________________________________________
3. __________________________________________________________________________
__________________________________________________________________________
4. ___________________________________________________________________________
__________________________________________________________________________
HAVE YOU MISSED ANY TIME FROM WORK AS A RESULT OF YOUR INJURY? YES [ ] NO [ ]
IF SO, LIST THE DATES YOU WERE UNABLE TO WORK:
FROM: ___________________ TO: ____________________________
FROM: ___________________ TO: _____________________________
17. LIST OF WITNESSES
1. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________
2. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________
3. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________
18. INFORMATION ON THE INJURY
STATE ALL INJURIES KNOWN TO BE A RESULT OF THE ACCIDENT: ___________________________
_________________________________________________________________________________
_________________________________________________________________________________
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LENGTH OF TIME CONFINED TO BED: ________________________________________________ ___
LENGTH OF TIME CONFINED TO HOUSE: ________________________________________________
STATE PRESENT CONDITIONSINCLUDING SCARS, DISABILITIES, DEFORMATIES, DISCOMFORTS, ETC.,
DUE TO THE INJURIES: _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
19. INFORMATION ON THE TREATMENTS
LIST ALL PHYSICIANS, NURSES, THERAPISTS, CHIROPRACTORS, SURGEONS, OR OTHER HEALTH
CAREPROFESSIONALS YOU HAVE SEEN FOR YOUR INJURIES
1. NAME/ TITLE____________________________________________________________________
ADDRESS__________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:_______________________________________________________
NATURE OF CARE____________________________________________________________________
__________________________________________________________________________________
DATE OF DISCHARGE: ______________________________________________________________
2. NAME/ TITLE____________________________________________________________________
ADDRESS_________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:______________________________________________________
NATURE OF CARE__________________________________________________________________
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DATE OF DISCHARGE: _______________________________________________________________
3. NAME/ TITLE____________________________________________________________________
ADDRESS__________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:______________________________________________________
NATURE OF CARE__________________________________________________________________
________________________________________________________________________________
DATE OF DISCHARGE:________________________________________________________________
20. INFORMATION ON SETTLEMENT OFFERS:
HAVE YOU RECEIVED ANY SETTLEMENT OFFERS FOR THIS INJURY? YES [ ] NO [ ]
IF SO, PROVIDE THE INFORMATION BELOW
DATE OF SETTLEMENT OFFER: _______________________________________________________
AMOUNT OF THE SETTLEMENT OFFER: $________________________________________________
NAME, ADDRESS AND TELEPHONE NUMBER OF THE COMPANY OR THE PERSON WHO OFFERED YOU
THE SETTLEMENT:_________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
21. INFORMATION ON THE DRIVER LICENSE
DRIVER’S LICENSE:_______________________________________________________________
DRIVER’S REGISTRATION:___________________________________________________ ______
CAR MODEL AND TYPE: ____________________________________________________ ______
INSURANCE COMPANY: ___________________________________________________________
ADJUSTER AND TELEPHONE NO.:_______________________________________________
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CLAIM/POLICY NO.:_______________________________________________________________
22. INFORMATION ON HEALTH INSURANCE:
__________________________________________________________________________
__________________________________________________________________________
23. CLIENT’S INSURANCE INFORMATION
DOES CLIENT OR ANYONE IN CLIENT’S HOUSE HAVE AUTO INSURANCE? YES [ ] NO [ ]
IF YES, STATE NAME AND ADDRESS OF INSURANCE OWNER:_________________________________
_______________________________________________________________________________
_______________________________________________________________________________
INSURANCE OWNER’S LICENSE: _______________________________________________________
INSURANCE OWNER’S CAR REGISTRATION: ____________________________________________
INSURANCE COMPANY: _____________________________________________________________
ADJUSTER AND TELEPHONE NO.:_____________________________________________________
CLAIM/POLICY NO.: _______________________________________________________________
24. DEFENDANT AND INSURANCE COVERAGE INFORMATION (VEHICLE WHICH STRUCK CLIENT)
NAME: _________________________________________________________________________
ADDRESS:________________________________________________________________________
__________________________________________________________________________________
TELEPHONE NO.: __________________________________________________________________
DEFENDAT’S LICENSE: ______________________________________________________________
DEFENDANT’S VEHICLE REGISTRATION: _________________________________________________
VEHICLE MODEL AND TYPE: __________________________________________________________
INSURANCE COMPANY NAME AND ADDRESS:_____________________________________________
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________________________________________________________________________________
________________________________________________________________________________
ADJUSTER NAME ADDRESS AND TELEPHONE NO.: ________________________________________
________________________________________________________________________________
________________________________________________________________________________
CLAIM/POLICY NO.: _______________________________________________________________
DEFENDANT ATTORNEY NAME ADDRESS, AND TELEPHONE NUMBER:__________________________
__________________________________________________________________________________
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25. FACTS OF CASE
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FOR OFFICE USE ONLY:
ATTORNEY NOTES AND CHRONOLOGY OF EVENTS:
ATTORNEY NOTES
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CHRONOLOGY OF EVENTS
DATES EVENT
1._______________________ ________________________________________________.
2. _______________________ ________________________________________________
3._______________________ ________________________________________________
4._______________________ ________________________________________________
5._______________________ ________________________________________________
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