New Client Information

Attorney Client Privileged & Confidential

Today's Date:

Date of Injury / Accident:

I. Personal & Family Information:

Full Name:

Maiden Name (If applicable):

SSN:

Date of Birth:

Present Home address:

Mobile Phone #:

Home Phone #:

Email Address:

Is it ok to send important communication & documents to you by email?

Name & Phone Number of friend or relative through whom you can be reached:

Were you married at the time of your injury?

Name of Spouse?

Still Married?

Employer:

Job Title:

Current rate of pay:

Missed any work as a result of your injury?:

II. Present Injury:

State all injuries known or believed by you to have been received as a result of this accident or occurrence (area of body and symptoms):

LIST ALL HEALTHCARE PROVIDERS RELATED TO INJURY

Please state all medical treatment and/or hospitalization as a result of this accident:

1.) Ambulance:

2.) Hospital Emergency Room (name the hospital):

First Date seen:

OTHER DOCTORS / THERAPISTS / IMAGING CENTERS, etc ...

1	Treatment complete? Phone #: Address:
2	Treatment complete? Phone #: Address:
3	Treatment complete? Phone #: Address:
4	Treatment complete? Phone #: Address:
5	Treatment complete? Phone #: Address:
6	Treatment complete? Phone #: Address:
7	Treatment complete? Phone #: Address:

III. Information about This Accident:

Date of Accident:

Location of Accident:

Police Department that Responded:

Police Report #:

Name of Responsible Party:

How did the accident happen?

Other Party’s Insurance Information (if known):

Insurance Company:

Claim # for this accident:

Insurance Adjuster / Phone #:

Your Auto /Liability Insurance Information:

Insurance Company:

Claim # for this accident:

Insurance coverage (if known):

1. Med Pay Coverage?

Amount:

2. Uninsured Motorist Coverage (UM Coverage)?

3. Underinsured Motorist Coverage (UIM Coverage)?

Your Health Insurance Information (if any):

Insurance Company:

Group Plan / Individual Plan? (if known):

IV. Prior Claims and/or Lawsuits:

We must know whether you have ever had ANY CLAIM or LAWSUIT (including claims for Worker’s Compensation) in your life, regardless or whether or not you collected any money from your claim or lawsuit.

Insurance companies have access to sophisticated and comprehensive databases regarding past claims and lawsuits asserted by you or on your behalf anywhere in the United States. Prior claims or lawsuits will usually not affect your present case, but a denial of such a prior claim or lawsuit will cause serious damage to your credibility and your current case.

Please list every claim you have made for personal injuries or medical bills arising out of personal injuries.

1	Date of Injury: Workers Compensation? Against Who: Lawsuit filed: Where: Injuries Claimed:
2	Date of Injury: Workers Compensation? Against Who: Lawsuit filed: Where: Injuries Claimed:
3	Date of Injury: Workers Compensation? Against Who: Lawsuit filed: Where: Injuries Claimed:

MORE THAN 3? -- If more will discuss with attorney.

V. Prior Accidents and Injuries:

Failure to mention other problems, diseases or injuries, to the same parts of your body that were hurt in your current case, can undermine or destroy a claim or lawsuit (no matter how trivial the prior injury, problem or disease may seem).

Please list any past injuries or problems with the areas of your body, injured in this case, whether they resulted in a claim for damages or not, stating (to the best of your recollection) the date, place and nature and extent of your injury or problem.

If you have had no prior injuries or problems with the areas of your body injured in this case, state “NONE”.

1	Date: Against Who: Name of Doctors or Hospitals involved:
2	Date: Against Who: Name of Doctors or Hospitals involved:
3	Date: Against Who: Name of Doctors or Hospitals involved:
4	Date: Against Who: Name of Doctors or Hospitals involved:

MORE THAN 4? -- If more will discuss with attorney.

The information submitted in this form is secure and confidential.

Attorney Client Privileged & Confidential

I. Personal & Family Information:

II. Present Injury:

LIST ALL HEALTHCARE PROVIDERS RELATED TO INJURY

OTHER DOCTORS / THERAPISTS / IMAGING CENTERS, etc ...

1

2

3

4

5

6

7

III. Information about This Accident:

Other Party’s Insurance Information (if known):

Your Auto /Liability Insurance Information:

Insurance coverage (if known):

Your Health Insurance Information (if any):

IV. Prior Claims and/or Lawsuits:

1

2

3

V. Prior Accidents and Injuries:

1

2

3

4