| General Contact Information: |
Your Name:
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Age of Injured Person:
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Street Address:
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City:
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State:
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Zip:
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E-mail Address:
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Best time to contact you:
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Phone Number:
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Work Number:
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Fax Number:
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Type of Accident:
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| Legal Issues: |
Have you contacted any other lawyer about your potential claim?
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If you answered yes to the previous question:
Did the lawyer agree to represent you?
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Are you still being represented by the lawyer?
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| General Incident Information: |
On what date were you injured (mm/dd/yyyy)?:
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In what city and state did the injury occur?
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Please briefly explain the incident that caused your injury:
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Who do you believe was at fault in causing your injury, and what do you believe
they did wrong?
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Please briefly describe your injuries:
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Were you taken to an emergency room:
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If yes, which hospital:
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Were you admitted as an inpatient to the hospital:
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If yes, which hospital:
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How many days were you an inpatient:
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Do you require physical therapy for your injuries:
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If yes, how often do you go to therapy:
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Are you still treating with a physician:
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What was the date of your last treatment (mm/dd/yyyy)?:
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What is the name of the physician and/or specialist treating you for your
injuries:
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Do you believe that any of your injuries are permanent?
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| Employment and Earnings: |
Are you currently collecting Workers' Compensation?
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Have you lost any earnings due to injury?
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Have you been released by a doctor to return to work?
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Do you believe you are too injured to return to work?
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Have you suffered any other losses (home, vehicles, etc...) because of this
injury and, if so, please describe your losses:
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| Insurance Issues: |
Have you notified your insurance company about this claim?
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Has the defendant's insurance company contacted you?
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| For automobile-related accidents only: |
Was a police report taken?
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If yes, was it taken by the state police or the local police?
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If local police, what is the name of the local police department:
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Do you have a copy of the police report?
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What was the damage to your vehicle?
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| How did you find our website: |
| Television Ad: |
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| Radio Ad: |
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| Newspaper Ad: |
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| Billboards: |
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| Referred by a Friend: |
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| Search Engine: |
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| Other: |
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| Any Additional Questions? |
Are there any other questions you wish to have answered?
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