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Client Personal Injury Application

Auto Accidents Only

* Indicates a Required Field

Client Information

*First Name:
*Last Name:
*Social Security #:
*Address:
Apartment/Suite:
*City:
*State:
*Zip Code:
*Home Phone:
Work Phone:
*Date of Birth:
E-Mail Address:
Occupation:
*Employer:
*Amount Requested:
*I have a Personal Injury Law Suit/Claim/Action:
Accident Description
 
*Date of Accident:
*Type of Vehicle:
*Position in Vehicle:
*Type of Accident:
*Impact:
 
*My Vehicle was:
Moving Stopped
Injuries/Damages
 
Vehicle Damage:
*Emergency Room:
I was admitted to the hospital:
Yes No
Stayed Overnight:
# of days in the hospital
*Most Serious Injury:
Describe Your Injury:
Health Care Providers that treated me:
*Procedures - Other:
Comments:
*I am still being treated:
Yes No
If no, when were you released?: (mm/dd/yyyy)
Lost Wages
 
*I have a lost wages claim:
Yes No
Disability
 
If you have a disability as a result of this accident, please explain:
Liability/Insurance
 
The police arrived at the scene:
Yes No
The defendant received a ticket:
Yes No
Defendant was injured:
Yes No
Defendant's insurance company paid for the property damage to my car.:
Yes No
*Defendant's Insurance Company:
*My Insurance Company:
I have un-insured motorist coverage:
Yes No Amount
I have under-insured motorist coverage:
Yes No Amount
I have a loss of consortion claim:
Yes No
 
 
Attorney Information
 
*Name:
*Firm:
*Address:
*City:
State:
*Zip Code:
*Telephone:
Fax:
Paralegal:

 

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