Personal Injury Interview

Your Email Address:

First Name:

Middle or Maiden Name:

Last Name:

Address:

Phone:

Date of Birth:

Place:

Social Security #:

Marital Status:

Date of Marriage:

Place of Marriage:

Spouse's Name:

Spouse's Birthdate:

Names and Birthdates of Children:

Employer:

Position:

Wage:

How Long:

Driver's License:

Insurance Carrier of Negligent Party:

Claim #:

Policy #:

Agent:

Date of Policy:

Limits:

Union or Private Health Insurance:

Any Other Type of Medical Benefits:

DATE OF INCIDENT:

TIME:

PLACE:

Invesitgated by:
State Patrol Sheriff Local Police

Name of Officer:

Badge #:

Case #:

Names and Addresses of Witnesses:

Name of Ambulance Called:

Name of Hospital Involved:

Name of Treating Physician:

Name of Attending Physician:


Medical History (include all diseases and injuries with dates):

Prior Lawsuits:

Prior L&I -- Workman's Compensation Claims:

Prior Accidents (dates):

Please describe any prsonal injury claims made:

Any involvement in previous litigation, lawsuits, bankruptcies, etc:


SPECIAL DAMAGES

Time Loss from work to date:

Property Damage (send estimates, repair bills to main office):

Transportation costs, car rental, etc (send bills to main office):

Other property damage or any other special damage other than personal injury:

Date of statements given by you to others:


PROSPECTIVE DEFENDANTS

Name:

Birthdate:

Address:

Phone Number:

Occupation:

Year:

License #:

Liability Carrier:

Policy #:

Claim #:

Adjustor:


FACTS: In your own words, describe how the incident occured.

Submit the form:

Clear the form: