Personal Injury Intake Form Step 1 of 10 10% This field is hidden when viewing the formDate of Intake Call MM slash DD slash YYYY Client InformationYour Name(Required) First Last Your Phone(Required)Your Email(Required) Your Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Birthday(Required) MM slash DD slash YYYY What's your Instagram handle?What's your Facebook name?What's your Twitter handle?What's your TikTok handle?Your Marital Status Single Married Divorced Your Spouse's Name Injury or Accident DescriptionWhat type of injury have you sustained?(Required)Car AccidentDog Bite / Animal AttackSlip and Fall / Trip and FallWorkplace InjuryDefective Product Caused InjuryPlease describe the incident in detail.Did you take pictures of the incident? Yes No Upload all of the pictures of the accident scene Drop files here or Select files Max. file size: 32 MB. Location of Incident(Required)Date of Incident(Required) MM slash DD slash YYYY Time of Incident(Required) Hours : Minutes AM PM AM/PM Were you working at the time of the incident? Yes No Slip and Fall InformationWhat were you doing immediately before the fall?What caused you to fall? (water? oil? object? uneven surface?)Did you actually see the hazard before falling? Yes No Were you hit by anything on the way down? Yes No Did you hit anything or fall on top of anything on the way down? Yes No Did you lose consciousness? Yes No Were there warning cones or signs? Yes No What hand was holding what? Car Accident InformationYour Driver's License NumberWhich state issued your driver's license(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingUpload photo of front of driver's licenseMax. file size: 32 MB.Upload photo of back of driver's licenseMax. file size: 32 MB.How many vehicles were involved?Who was driving the car you were in?This field is hidden when viewing the formNumber of Days Since AccidentThis number should not be greater than 500 days. SOL runs at day 750.Weather ConditionsWhere were you driving from?Where were you driving to?Were the police called to the scene? Yes No What county police department reported to the scene?Did the other driver receive a ticket? Yes No I’m not sure Accident/Incident Report Number Injuries to Your BodyAre you hurt or injured? Yes No Select All That Are True: My head hurts I jerked into the seat in front of me My knee, ankle, elbow, or other bone(s) hurt My back hurts The pain has gotten worse since I went to the ER I haven’t talked to a doctor about the new pains I’m experiencing I struggle to do everyday tasks like eat, sleep, think My airbag deployed I hit my head on the steering wheel My seatbelt hurt me I’ve been limping or struggling to walk My whole body is in pain New parts of my body hurt since my ER visit I’ve been forgetting simple things The ER put me in a boot, sling, cast or other support device My passenger’s airbag deployed Please describe your injuries. (Soreness, aches, numbness, tingling, and or/ radiating pain)Upload pictures of your injuries, if you have any: Drop files here or Select files Max. file size: 32 MB. Did you go to the hospital? Yes No If yes, what hospital?Were you transported by ambulance? Yes No Property DamageIs the vehicle drivable? Yes No Estimated DamagePlease enter a number greater than or equal to 100.Where is your vehicle located?Your Vehicle's Year, Make, & ModelYour Vehicle's License Plate NumberWhich state is on your license plate?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingVINFull Name of Registered Owner of Vehicle Other Vehicle Insurance InformationOther Driver's NameOther Driver's License/State ID NumberWhich state issued the other driver's license/ID?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate of Birth of the Other Driver MM slash DD slash YYYY Year, Make, & Model of the Other VehicleVehicle Color for the Other VehicleLicense Plate Number on the Other VehicleWhich state is on the other vehicle's license plate?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAuto Insurance Provider for Other DriverPolicy Number for Other DriverClaim Number for Other DriverAdjuster's Name for Other DriverAdjuster's Phone Number for Other Driver Your Auto Insurance CoverageDo you have any auto insurance policy? Yes No Your Auto Insurance ProviderYour Auto Insurance Policy NumberMedical Payment Coverage included in your auto policy? PIP MedPay None Do You Have Uninsured/underinsured Motorist Coverage? Yes No Under/Uninsured Motorist Coverage AmountDid you file a claim with your auto insurance company? Yes No Claim Number from your auto insuranceAdjuster's Name from your auto insuranceAdjuster's Phone Number from your auto insuranceAre you covered through your employer's insurance? Yes No Please provide company & agent:Witness InformationWitness Full NameWitness's Phone Number Health InsuranceDid you use your health insurance for treatment related to this incident? Yes No Name of Your Medical Insurance CarrierWhat's Your Medical Insurance Member ID or Group #Do you have Medicaid or Medicare? Yes No Please upload a picture of the Front and back of your Medicaid or Medicare card(s) Drop files here or Select files Max. file size: 32 MB, Max. files: 2. Recorded StatementHave you given a recorded statement to anyone? Yes No If yes, who was it given to?Passenger 1 InformationPassenger 1 Full NameWhat's your relationship to Passenger 1?Passenger 1 Phone NumberPassenger 1 Date of Birth MM slash DD slash YYYY Passenger 1 Position in Vehicle Front Seat Behind Driver Middle Seat Behind Front Passenger Passenger 1 Medical Treatment Hospital Ambulance None Does he/she (Passenger 1) have Medicaid? Yes No Passenger 2 InformationPassenger 2 Full NameWhat's your relationship to Passenger 2?Passenger 2 Phone NumberPassenger 2 Date of Birth MM slash DD slash YYYY Passenger 2 Position in Vehicle Front Seat Behind Driver Middle Seat Behind Front Passenger Passenger 2 Medical Treatment Hospital Ambulance None Does he/she (Passenger 2) have Medicaid? Yes No Passenger 3 InformationPassenger 3 Full NameWhat's your relationship to Passenger 3?Passenger 3 Phone NumberPassenger 3 Date of Birth MM slash DD slash YYYY Passenger 3 Position in Vehicle Front Seat Behind Driver Middle Seat Behind Front Passenger Passenger 3 Medical Treatment Hospital Ambulance None Does he/she (Passenger 3) have Medicaid? Yes No Emergency ContactEmergency Contact Full NameEmergency Contact Phone NumberHow Did You Hear About Us?!Please select one: Referral Instagram Facebook In Person Other Name of Person Who Referred YouThis field is hidden when viewing the formHow do you want to contact to be generated Send the contract to the client via email Generate the contract to be signed right now Δ