Personal Injury Intake Form

Name:

Please enter your name.

Address:

Please enter your street address.

City:

Please enter the name of your city.

State:

Please choose your state of residence.

ZIP Code:

Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) – + characters.

Email Address:

Please enter a valid email address.

Home Phone:

Please enter a valid home phone number. You may use 0-9, spaces and the ( ) – + characters.

Business Phone:

Mobile Phone:

Fax Number:

Who was injured?

If “Other,” please describe:

Injured person’s name (if different from above):

Address:

City:

State:

ZIP Code:

Email Address:

Home Phone:

Business Phone:

Mobile Phone:

Fax Number:

When did the injury occur?

Where did the injury occur?

Describe any injuries that occurred:

In your opinion, what caused the injuries?

In your opinion, who caused these injuries?

What is your estimate of total medical expenses so far?

What is your estimate of the total lost income so far?

Was this location the injured person’s

If yes, who owns the property?

How did the injury happen?

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

If yes, what are the witnesses names/contact information?

If yes, what are their names/contact information?

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):

Where did you hear about this website?

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