Accident 2

    First and Last Name

    Email Address

    Phone Number

    Mailing Address

    Alternate Contact Name

    Alternate Contact Phone

    Type of Case: (Check All That Apply)
    Automobile AccidentMotorcycle AccidentDefective ProductOn-The-Job-AccidentWrongful DeathClaim against GovernmentTruck AccidentPremise LiabilityPedestrianBicycle AccidentAssault ClaimMedical MalpracticeTrain AccidentConstruction AccidentNursing Home AbuseOther


    When did your injury occur?

    Describe Incident and Your Injuries:

    Do you have health insurance (Blue Cross, Aetna, Medicare, Medicaid, etc.)?

    If yes, what is the name of the health insurance company:

    Was there an "Accident Report" or "Incident Report" done?

    If so, who made the report:

    Do you have any photographs or other recordings of the accident, scene, vehicles or any injuries incurred? Please upload
    [dropuploader dropuploader-294 limit:25MB multiple ajax]

    Did you go to the Emergency Room?

    If yes, where you taken by Ambulance?

    From which ER did you receive treatment? (Name and Address)

    Do you have a General Treating Clinic or Physician?

    If yes, who is your General Treating Clinic or Physician?

    Have you had any surgeries as a result of the accident?

    If yes, what where they for and when:

    Have you had any epidurals or other pain related injections as a result of the accident?

    If yes, what where they for and when:

    Have you received other medical treatment?

    If yes, please name each hospital, doctor, physical therapist, etc., where you received treatment regarding this incident?

    Have you talked to an Insurance Claims Adjustor?

    If yes, what is their name and the name of their company?

    Have you signed any paperwork from an insurance company since your accident whether it is your own insurance company or the other parties insurance company?

    If you have signed paperwork do you still have a copy of what you signed?

    Have you received any compensation for the accident?

    If so, who paid you the compensation?

    How much was the compensation?

    Are you currently taking medication?

    If yes, what is type?

    Where do you have this medication filled?

    Do you know the total of your current medical bills?

    if yes, how much are they?

    ER Hospital Bill:

    Ambulance Bill:

    ER Doctor's Bill:

    General Doctor's Bill:


    Mileage Costs:

    Time Spent in the Emergency Room:

    Time Spent at the Doctor's Office:

    Pharmacy Bills:

    Other Bills Incurred Because of the Accident

    Have you had any surgeries prior to the accident?

    If yes, what where they for and when?

    What other, if any, medical problems did you have before this injury?

    Did you miss any time from work because of the accident or injury?

    If yes, how much time have you missed from work?

    How much do you make per hour or per pay period?

    Was your husband, a friend or a relative required to miss work to help you because of your accident or injury?

    Are you on Social Security Disability or SSI?

    If yes, what is the basis of your benefits?

    Have you ever filed a lawsuit before?

    If yes, where and against who? Please provide the name and address.

    How did the Caller Hear of US?

    Referral, if so, by who?

    Who completed this online intake?

    First and Last Name of Person Completing Form:

    Required fields

    While we are honored that you are submitting this online intake this is no intended to engage you into an attorney-client relationship with our firm. We only consider you to be a client after we have received a signed contract, whether it is signed in person or electronically.

    Designed & Developed by sleon productions