Personal Injury Interview Form

Date:
Statute of Limitations:
Submitter's Name:

CLIENT'S PERSONAL INFORMATION

VICTIM'S FULL NAME (if different from submitter):

ADDRESS:
CITY:
State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP:
TELEPHONE:
(H)
(O)
(C)
COUNTY OF RESIDENCE:
EMAIL ADDRESS:

GENDER: M / F
SOCIAL SECURITY #:
DATE OF BIRTH:
AGE:
MARITAL STATUS:
DRIVER' LICENSE #:
STATE:
EXP:
SPOUSE/PARTNER'S NAME:
CHILDREN: (NAMES & AGES)

EMPLOYMENT

OCCUPATION:
EMPLOYER:
HOW LONG?:
SCHEDULE/SHIFT:
HOURLY WAGE:
OVERTIME: YES NO
EDUCATION:

INCIDENT INFORMATION

DATE & TIME:
LOCATION:
INVESTIGATED BY:
VICTIM'S ROLE (Driver, Passenger, Owner, Pedestrian)
OTHER PERSONS IN CAR:
TYPE OF VEHICLE:
PARTIES RESPONSIBLE FOR INCIDENT:
CHARGES FILED?
COURT DATE?
VIDEOS/PHOTOGRAPHS AVAILABLE?
WHOSE POSSESION?
DESCRIPTION OF INCIDENT:

WITNESSES

(Indicate at right (Yes) or (No) if statements were made to insurance adjuster/officer)

Name: Address: Phone(s):

1. Yes No
2. Yes No
3. Yes No
4. Yes No

OTHER POTENTIAL ISSUES:

WEATHER:
ALCOHOL/DRUGS:
SEATBELTS:
COMPARATIVE NEGLIGENCE:
MECHANICAL FAILURE:
OTHER CONSIDERATIONS:

INJURIES AND DAMAGES

PLEASE DESCRIBE YOUR INJURIES:

MEDICAL TREATMENT:

PHYSICIAN NAME - SPECIALITY - COMPLETE MAILING ADDRESS - PHONE

PHARMACY NAME COMPLETE MAILING ADDRESS PHONE

LOST WAGES

PRIMARY EMPLOYER:
WAGES:
HOURLY:
WEEKLY
OTHER
TIME MISSED:
CONTACT PERSON FOR VERIFICATION:
PHONE:
ADDRESS:

SECONDARY EMPLOYER:
WAGES:
HOURLY:
WEEKLY
OTHER
TIME MISSED:
CONTACT PERSON FOR VERIFICATION:
PHONE:
ADDRESS:

PREVIOUS LITIGATION

Please list prior law suits or claims. Include dates and locations and previous attorneys.

EVIDENCE

1. Please attach photographs of vehicle damage or property damage. We require hard copies that we may keep or email digital files to andrea@lowcountrylawyer.com.
2. Please attach photographs of injuries to victim(s), such as visible laceration, stitches, bruises, swelling, cast, braces, etc... We require hard copies that we may keep or email digital files to andrea@lowcountrylawyer.com.
3. Attach or mail copy of victim's insurance declaration page or "dec page".
4. Provide all billing statements for services rendered by healthcare providers such as physician, hospital, rehabilitation, emergency room, x-ray, MRI, physical therapy, home healthcare, emergency transport and pharmacy receipts.

HOW WERE YOU REFERRED TO OUR OFFICE?