POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY
Date: Lawyer: Date of Accident:
I. CLIENT INFORMATION
Client Name: Date of Birth:
First Middle Last
You would be preferred to be called (nickname): Gender: ___ Male ___ Female If Client Under 18 years of age, Parent’s or Guardian’s Name:
Address: City/State/Zip:
Home Phone No: Work Phone No: Cellular Phone No:
Fax Number: Email Address:
Driver’s License Number: Social Security Number:
(Please include the state issued in) (We need this number for our records)
Marital Status: Spouse’s Name & Number: Two (2) Names and Phone Numbers for Emergency Contacts: 1)
2) Please provide your screen name(s).
FACEBOOK name: TWITTER name:
MySpace name: Other internet name:
IMPORTANT
*SOCIAL NETWORKING SITES: Any information about you on social networking sites (i.e., Myspace, Facebook, blogs, etc.) is readily available for the insurance company(ies). It is a means for them to evaluate your personality, credibility, and character. You can guarantee that an insurance company and its legal representatives will search these sites and the web in general for information they can use against you to avoid or limit payment. Therefore, you must remove and refrain from placing any content that could paint you in a negative light.
HOW DID YOU HEAR ABOUT OUR LAW FIRM? Attorney’s Signature:
Who Can We Thank For The Referral? (Please check all that apply.)
TV Yellow Pages Seminar Website / Internet
By An Attorney By A Friend You Were / Are a Current / Previous Client By A Physician Reputation By A Previous / Current Client
Bus Stop Signs Drive By / Walk In (Outdoor Sign) Answering Service Other
LANGUAGE PREFERENCE
II. EMPLOYMENT INFORMATION/WORK ABSENCE
Were you on the job at the time of the incident? (select one) Yes or No
Employer’s Name: Phone Number:
Address: City/State/Zip:
Your Job Position: Your Supervisor:
Have you lost any wages? How much do you make per hour or by salary? Avg. tip? Commission? Other? How many hours per day do you work?
Time lost from work: Days Hours Will you lose further time from work? Do you have a Doctor’s excuse?
Social Security and Social Services Information:
1. Have you been determined to be disabled? (select one) Yes or No When?
2. If you answered No to No. 1, have you applied for social security disability? (select one) Yes or No When?
3. Do you receive public assistance based on your level of income? (E.g., Medicaid, social services, Social Security Supplemental Income or “SSI”, county assistance programs, food stamps, etc.) (select one) Yes or No 4. If you answered Yes to No. 3, what public assistance do you receive?
III. HEALTH INSURANCE INFORMATION
Primary Health Insurer (e.g., Medicare, HPN, Culinary): Member No:
Address: Phone No:
Secondary Health Insurer (e.g., AARP, Senior Dimensions): Member No:
Address: Phone No:
Would you like for your medical provider(s) to bill your health insurance? (select one) Yes or No (Please provide our office with a copy of the front and back of your insurance cards.)
IV. INCIDENT INFORMATION (Please continue in section H. if you need more room)
A. Health Care Providers (Ambulance, Hospital, Doctor, Chiropractor, Physical Therapy, Pharmacy, etc.):
1. Name: Phone No:
3. Name: Phone No: Address:
Dates of Treatment (from – to): Purpose of Visit:
4. Name: Phone No:
Address:
Dates of Treatment (from – to): Purpose of Visit:
5. Name: Phone No:
Address:
Dates of Treatment (from – to): Purpose of Visit:
B. Injuries from Current Incident:
_________________________________________________________________________________________________ _________________________________________________________________________________________________
C. Wrongdoer/Defendant Information & Defendant’s Insurance Information:
1. a. Name of Business/Premises: Phone Number:
Address:
Insurance Carrier: Phone Number:
Address:
Policy No: Claim No:
Adjuster’s Name: Adjuster’s Phone No:
2. Did you fill out an Incident Report? If so, when and to whom given? 3. Did you give a Recorded Statement? If so, when and to whom given?
D. Facts of Incident
Date: Time: Place:
Indoors or Outdoors? Weather: What were you carrying?
Describe the shoes you were wearing: Still have them? What were you looking at when the accident happened?
What, if anything, was said by the employees?
What evidence do you have that the business should have known of the danger before you fell?
What evidence do you have that the business actually knew of the danger before you fell?
Damage to your clothes or any other items:
Did you tell anyone that you were hurt? When? Who did you tell? Any visible injuries immediately after fall? What?
If Photographs taken of scene, when? What?
If Photographs taken of you, by whom? When? Of what? Facts of Incident:
Diagram of Incident:
Were you accompanied by anyone? By whom or who? Please state each person’s name, address and telephone number:
1. Name: Phone No:
Witnesses: 1. Name: Phone No:
(including employees) Address: Relation to you:
2. Name: Phone No:
Address: Relation to you:
3. Name: Phone No:
Address: Relation to you:
E. Prior Accidents or Injuries (e.g., Auto, Slip and Fall, On the Job, etc.):
DATE DESCRIPTION INJURIES DOCTOR/HOSPITAL, ETC.
1. 2. 3. 4. 5.
F. Prior Similar or Same Pain, Conditions or Treatment (e.g., back/neck/shoulder/knee pain; surgery): 1.
2. 3. 4.
G. Criminal History:
Have you been convicted of a felony or been released from parole within the last 10 years? ______
H. OTHER
Please state any other information you feel that we should be aware of:
