DATE: INTAKE BY: SLIP & FALL AUTO ACCIDENT PERSONAL INJURY FULL NAME: IF MINOR PARENTS= NAMES: HAVE YOU EVER USED OR BEEN KNOWN BY ANY OTHER NAME THAN THAT SHOWN ABOVE? IF SO, PLEASE LIST EACH SUCH NAME, INCLUDING WHEN AND WHY YOU USED IT. HOME ADDRESS: CITY: STATE: ZIP CODE: HOW LONG HAVE YOU LIVED IN FLORIDA? HOME #: CELL#: E-MAIL: WORK #: IS IT OK IF WE SEND YOU E-MAILS ON BREAKING LEGAL NEWS OR ITEMS COMING OUT OF OUR OFFICE NOT RELATED TO THE CASE THAT WE ARE HANDLING FOR YOU. Yes No SSN: DOB: WHERE WERE YOU BORN? DRIVER LICENSE NO. & STATE: NAME, ADDRESS, & TELEPHONE NUMBER OF EMERGENCY CONTACT: MARITAL STATUS: SPOUSE: Anniversary: IF SEPARATED, GIVE DATE OF SEPARATION: LIST ALL DEPENDENTS, INCLUDING NAMES, AGE AND RELATIONSHIP: 1
EMPLOYMENT INFORMATION WERE YOU EMPLOYED AT THE TIME OF ACCIDENT? EMPLOYER=S NAME: EMPLOYER=S ADDRESS: JOB TITLE: JOB DUTIES: RATE OF PAY:$ ( )HOURLY ( )WEEKLY ( ) BI-WEEKLY ( ) MONTHLY ( ) YEARLY HOW OFTEN DO YOU WORK? HOURS PER DAY DAYS A WEEK ( - ) LENGTH OF EMPLOYMENT: IF LESS THAN 13 WEEKS PRIOR TO ACCIDENT, PROVIDE PRIOR EMPLOYMENT INFORMATION AS REQUESTED ABOVE: HAVE YOU LOST TIME FROM WORK? DATE DISABILITY BEGAN: DATE DISABILITY ENDED: TO DATE, HOW MUCH INCOME HAVE YOU LOST FROM WORK? WORKERS COMPENSATION AT THE TIME OF THE ACCIDENT, WERE YOU IN THE COURSE AND SCOPE OF YOUR EMPLOYMENT? IF YES, WHAT WERE YOU DOING? HAS A WORKERS COMPENSATION CLAIM BEEN FILED? WHAT IS THE NAME/ADDRESS/CLAIM NUMBER FOR YOUR WORKERS COMPENSATION CARRIER? 2
ACCIDENT/INCIDENT DATE: TIME: PLACE OF ACCIDENT: CITY: COUNTY: STATE: DAYLIGHT/DARKNESS: WEATHER: WHERE WERE YOU COMING FROM AND WHERE WERE YOU GOING TO? PROVIDE A DETAILED ACCOUNT OF HOW THE INCIDENT OCCURRED: PLEASE LIST ALL WITNESSES: NAMES, ADDRESSES & TELEPHONE NUMBERS: 3
AUTOMOBILE ACCIDENTS ONLY WERE YOU DRIVER OR PASSENGER: HOW MANY IN VEHICLE? IF YOU WERE THE PASSENGER, WHO WAS DRIVING? WAS A LAW OFFICER CALLED TO THE SCENE? WHAT DEPARTMENT? WAS AN ACCIDENT REPORT MADE? ACCIDENT REPORT NO.: WERE YOU QUESTIONED BY THE POLICE? WERE PICTURES TAKEN AT THE SCENE OF THE ACCIDENT? BY WHOM? WHEN? WERE YOU WEARING A SEAT BELT AT THE TIME OF THE ACCIDENT? WHAT WAS THE YEAR, MAKE, AND MODEL OF THE VEHICLE YOU WERE IN? WHO OWNED THE VEHICLE? PROPERTY DAMAGE:$ WAS VEHICLE TOTALED? HAS PROPERTY DAMAGE BEEN SETTLED? CLIENT NEEDS HELP: DO YOU NEED A RENTAL CAR? HAVE PHOTOGRAPHS BEEN TAKEN OF PROPERTY DAMAGE? BY WHOM? WHEN? WHERE IS YOUR VEHICLE LOCATED? DESCRIBE PROPERTY DAMAGE TO YOUR VEHICLE: MILD MODERATE SEVERE DESCRIBE PROPERTY DAMAGE TO OTHER VEHICLE: MILD MODERATE SEVERE NOTE: PLEASE PROVIDE YOUR ATTORNEY WITH THE PROPERTY DAMAGE/VALUATION ESTIMATE, REPAIR BILLS, AND RECEIPTS. PIP / UM INSURANCE INFORMATION NAME OF YOUR AUTOMOBILE INSURANCE COMPANY: POLICY HOLDER: POLICY NUMBER: CLAIM #: PHONE #: HAS PIP APPLICATION BEEN SENT TO YOUR INSURANCE COMPANY? PIP DEDUCTIBLE? AMT:$ MEDICAL PAYMENTS? AMT:$ UM COVERAGE? AMT:$ COLLISION? DEDUCTIBLE? 4
DID YOU PROVIDE A RECORDED STATEMENT TO THE INSURANCE COMPANY? WHEN? TO WHOM? NUMBER OF MOTOR VEHICLES IN YOUR HOUSEHOLD: DESCRIBE ANY MOTOR VEHICLES THAT YOU OWNED AT THE TIME OF THE ACCIDENT (INCLUDING YEAR, MAKE AND MODEL): WERE THESE VEHICLES OPERABLE? DESCRIBE ALL MOTOR VEHICLES OWNED BY RELATIVES YOU RESIDE WITH ON THE DATE OF THE ACCIDENT: RELATIVES NAME VEHICLE INS. CO. RELATIVES NAME VEHICLE INS. CO. DOES ANYONE IN YOUR HOUSEHOLD USE A COMPANY VEHICLE? DO YOU HAVE A CAR YOU BRING HOME FROM WORK? YES NO AT FAULT DRIVER / OWNER INSURANCE INFORMATION AT FAULT DRIVER S NAME: AT FAULT DRIVER S ADDRESS: AT FAULT OWNER S NAME (if different from driver): AT FAULT OWNER S ADDRESS: AT FAULT OWNER S INSURANCE COMPANY: TELEPHONE NUMBER: POLICY NUMBER: CLAIM NUMBER: AT FAULT DRIVER S INSURANCE COMPANY: TELEPHONE NUMBER: POLICY NUMBER: CLAIM NUMBER: DID YOU PROVIDE A STATEMENT TO THESE INSURANCE COMPANIES? WHICH COMPANY? WHEN? DID AT FAULT DRIVER HAVE A BUSINESS SIGN ON VEHICLE? YES NO. WHAT WAS THE NAME ON THE SIGN: 5
PREMISES LIABILITY INCIDENTS ONLY PROPERTY OWNER=S NAME & ADDRESS: PROPERTY OWNER=S INS. CO.: POLICY NUMBER: CLAIM NUMBER: WAS AN INCIDENT REPORT FILED? DO YOU HAVE A COPY OF THE REPORT? DID YOU SIGN THE INCIDENT REPORT? DID YOU PROVIDE AN ORAL OR WRITTEN STATEMENT? WHEN? FOR WHOM? WERE PICTURES TAKEN OF THE SCENE OF THE ACCIDENT? BY WHOM? WHEN? HEALTH INSURANCE INFORMATION CARRIER S NAME: MEMBER: GROUP NO.: CONTRACT NO.: MEDICAID NO.: MEDICARE NO.: INJURIES/TREATMENT HEAD: LOC LAC CONCUSSION HEADACHE NECK : PAIN SWELLING BACK: PAIN UPPER MID LOWER R-ARM/SHO: NUMBNESS TINGLING RADIATING PAIN L-ARM/SHO: NUMBNESS TINGLING RADIATING PAIN R-LEG/BUTT : NUMBNESS TINGLING RADIATING PAIN L-LEG/BUTT: NUMBNESS TINGLING RADIATING PAIN OTHER: HOW DID YOU LEAVE THE SCENE OF ACCIDENT: 6
HOSPITALS AT WHICH YOU HAVE TREATED FOR THIS ACCIDENT NAME/ADDRESS OF HOSPITAL: DATE ADMITTED: DATE DISCHARGED: NATURE OF TREATMENT: ********** NAME/ADDRESS OF HOSPITAL: DATE ADMITTED: DATE DISCHARGED: NATURE OF TREATMENT: PHYSICIANS/SURGEONS WITH WHOM YOU HAVE TREATED NAME/ADDRESS OF PHYSICIAN: NATURE OF TREATMENT: DATE CARE BEGAN: STILL UNDER CARE? ********** NAME/ADDRESS OF PHYSICIAN: NATURE OF TREATMENT: DATE CARE BEGAN: STILL UNDER CARE? ********** NAME/ADDRESS OF PHYSICIAN: NATURE OF TREATMENT: DATE CARE BEGAN: STILL UNDER CARE? OUT OF POCKET EXPENSES/OBLIGATIONS YOU ARE CLAIMING PLEASE PROVIDE A LISTING OF ALL DEBTS/CHARGES OWED OR PAID AS A RESULT OF THIS ACCIDENT, INCLUDING PRESCRIPTIONS, TOWING, HOSPITAL BILLS, ETC. 7
PAST MEDICAL HISTORY NECK DX: DR: BACK DX: DR: ARMS DX: DR: LEGS DX: DR: SURG. DX: DR: CHRONIC DX: DR: PSYCH DX: DR: OTHER DX: DR: PRIOR ACCIDENTS/INJURIES AND CLAIMS/LAWSUITS FAILURE TO MENTION OTHER ACCIDENTS/INJURIES OR CLAIMS/LAWSUITS CAN UNDERMINE A LAWSUIT, NO MATTER HOW TRIVIAL THEY MAY SEEM. ACCIDENTS (A/A, S&F, ETC.) WORKERS COMP. CLAIMS TYPE: TYPE: WHEN: WHEN: WHERE: WHERE: INJURY: INJURY: DR/HOSP: DR/HOSP: RESULT: RESULT: INJ. TO SAME BODY PART SUBSEQUENT INJURY/ACCIDENTS TYPE: TYPE: WHEN: WHEN: WHERE: WHERE: INJURY: INJURY: DR/HOSP: DR/HOSP: RESULT: RESULT: 8
HOBBIES / INTERESTS WHAT ARE YOUR HOBBIES OR AREAS OF INTEREST? LIST ALL ACTIVITIES THAT HAVE BEEN ELIMINATED OR HAMPERED AS ARESULT OF YOUR INJURIES, SUCH AS MOWING THE LAWN, HOUSEHOLD CHORES, DANCING, SPORTS, SLEEPING, ETC. MILITARY BACKGROUND HAVE YOU EVER SERVED IN THE MILITARY? BRANCH: DATES OF SERVICE: TO RANK/RATE: TYPE OF DISCHARGE: CURRENT DUTY STATION ADDRESS: EDUCATIONAL BACKGROUND HIGHEST GRADE/LEVEL COMPLETED: ANY SPECIAL EMPLOYMENT/SKILLS TRAINING: HOW DID YOU HEAR ABOUT OUR FIRM? TELEVISION RADIO PHONE BOOK BILLBOARDS NEWSPAPER FRIEND/RELATIVE PHYSICIAN INTERNET OTHER (EXPLAIN) 9
Investigator: Date: Overview Worksheet Client Name: Case Type: Best Treating Location: Synopsis of Accident: Insurance Info (Coverage Info if Available): Client: AFD: Special Details/Urgent Requests: Photograph: Y/N Photograph Type: PD / Scene / Client Notes: File Assignment:
ON THE DIAGRAM, PLEASE CIRCLE OR PLACE AN X ON THE PART(S) OF YOUR BODY THAT WAS INJURED
PLEASE DRAW ON THE DAGRAM HOW YOUR ACCIDENT OCCURRED Use the diagram to reconstruct the locations of the cars and witnesses. Show the direction of travel of all the vehicles, the location of traffic signals and signs and any other makings or characteristics of the scene.