Slip & Fall Intake

Published on May 2016 | Categories: Types, Legal forms | Downloads: 16 | Comments: 0 | Views: 193
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Law Firm Intake for potential clients to fill out

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Content

SOL:__________
SLIP & FALL INJURY
INTAKE SHEET
INITIAL CLIENT STATEMENT
Instructions: Please complete the form below to the best of your ability. The information
provided will help us efficiently evaluate your case. Thank You.
HOW DID YOU HEAR ABOUT OUR OFFICE OR WHO REFERRED YOU:
(INDIVIDUAL, YELLOW PAGE AD, ETC…)
______________________________________________________________________
PERSONAL INFORMATION:
NAME: ______________________________________________________________________
Address: ______________________________________________________________________
City:__________________________________________________ Zip:____________________
Telephone # (home)________________________ (cell/pager) ___________________________
(work) _________________________ (email address) _________________________________
Age: ________ Date of Birth: ________________ Social Security # _____________________
License # _________________________
EMPLOYER: _________________________Address_________________________________
Rate of pay: (hourly, weekly, monthly)____________________Occupation_________________
SPOUSE’S NAME: _______________________________Work phone___________________
EMERENCY CONTACT:
Name: ______________________________ Address: ____________________________
Relationship: _________________________ Phone: _____________________________
CHILDREN:
Name(s)/Age(s):________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EDUCATION:

High School/G.E.D. __________ Year of Graduation: _______________________
College/University: _________________________ Years & Degree: ________________
ACCIDENT INFORMATION:
Accident date: ________________ Day of week: ___________ Time: ________(am/pm)
Location: (Be Specific) _____________________________________________________
________________________________________________________________________

DESCRIPTION OF ACCIDENT: (BE SPECIFIC—GIVE AS MUCH DETAIL AS
POSSIBLE) ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

HEALTH INSURANCE COVERAGE
Name of Carrier: _______________________________________________________________
Benefit Plan (Company):_________________________________________________________
Your ID No.: ________________________________________
Has anyone from your health insurance company contacted you about this claim? _____
Name of Person who contacted you:________________________________________________
When

was

contact

made?

___________________________________________________

If a statement was given, was it tape recorded or written? _________________________
Did you receive a copy? __________________________________________________________
Have you signed any authorizations to release information to anyone? _______________

SECONDARY HEALTH INSURANCE
Name of Carrier: _______________________________________________________________
Benefit Plan: ___________________________________________________________________
Your ID No.: ________________________________________
Has anyone from your health insurance company contacted you about this claim? _____
Name of Person who contacted you:________________________________________________

MEDICAL INFORMATION
Were you injured in this accident? Describe: ___________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Did you go to the hospital? _____Which hospital? _______________________________
Admitted or OPD? _____________ If admitted, when released? ____________________
X-Rays taken? _________________ Were you taken by ambulance? ________________
Are you under the care of a physician now? ____________________________________
Please list all Doctors or Medical facilities including ambulances of any kind you have seen
as a result of this accident.
1. Name: ___________________________________ Phone: __________________
Address: _____________________________________________________________
2. Name: ____________________________________ Phone: __________________
Address: _____________________________________________________________

3. Name: _____________________________________ Phone: _________________
Address: _____________________________________________________________
4. Name: ______________________________________ Phone:________________
Address: _____________________________________________________________
Was anyone else injured in the accident? If so Whom? ______________________________
NAME AND ADDRESS OF ALL PARTIES INVOLVED:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If you have sustained injuries similar to the ones sustained in this accident on a prior occasion or
have seen a doctor for injuries or treatment for the same or similar injuries please describe the
injury:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Prior claims and/or settlements (types, dates, attorneys):_________________________________
WITNESSES:
Name

&

address

of

any

witness:

________________________________________

_____________________________________________________________________
Telephone Number: ____________________________________________________
Do you have photos pertaining to the scent or to your injuries:____________________________

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