Personal Injury Intake form

Name:

Street Address:

City:

State:

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Zip:

Phone:

Fax:

Email:

How would you like to be contacted?
 Email  Phone  Fax  Postal Mail
Who was injured?
Me Family Member Other
If "Other," please describe:

Injured person's name & contact Info. (if different from above):

When did the injury occur?

Where did the injury occur?

Did the injury occur as a result of a road accident?
Yes or No Yes No
Did the injury occur as a result of employment activities?
Yes or No Yes No
Did the injury occur on another's property?
Yes or No Yes No
If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes or No Yes No
If yes, what are their names/contact information?

Were others involved or injured at the same time?
Yes or No Yes No
If yes, what are their names/contact information?

Was there a police report?
Yes or No Yes No
Did the injured person receive medical treatment?
Yes or No Yes No
If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes or No Yes No
Was the injured person killed as a result of the accident?
Yes or No Yes No
If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

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