General Inquiry Form

Privileged and Confidential Attorney / Client Communication

GENERAL INJURY QUESTIONNAIRE

PERSONAL INFORMATION

Full Name

Street Address

City

State

Country

Postal code

Email *

Phone

Age

Date of Birth

Social Security Number

Employer

Occupation

Prior similar injuries - please list all medical conditions and/or symptoms or injuries to same area to your body as the current injury, that occurred PRIOR to the incident:

Prior claims and/or settlements - please list all prior automobile or other personal injury claims you’ve ever had prior to this incident, if any (types, dates, attorneys)

INJURY INFORMATION

***PLEASE PROVIDE A COPY OF THE POLICE REPORT IF YOU HAVE ONE. You may submit a digital copy here. Otherwise, you can provide a paper copy later on. ALL ORIGINAL COPIES WILL BE RETURNED TO YOU.

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PDF, DOCX, DOC, JPEG, JPG or PNG

Injury Date

Location (Be Specific)

Where Were You Coming From?

Where Were You Going?

DETAILS OF INCIDENT

Weather Condition

Any Construction in the Area? (Describe)

DESCRIPTION OF INCIDENT (BE SPECIFIC & PROVIDE AS MUCH DETAIL AS POSSIBLE)

Under the Influence of Any Alcohol or Drugs?

Did Anyone (Including Yourself) Admit Fault?

Who Made Such a Statement, if any?

What Was Said?

Did Anyone Make a Recorded Statement to an Insurance Company? If so, Which Company?

Who Made the Recorded Statement to Insurance (if any)?

What Was Said on the Recorded Statement to Insurance?

Were Photographs Taken of the Scene? By Whom?

****IMPORTANT: PROVIDE COPIES OF ALL PHOTOGRAPHS IN YOUR POSSESSION. WE WILL COPY AND RETURN ALL PHOTOGRAPHS TO YOU. Upload up to 5 images below.

Upload Up To 5 Images

PNG, JPEG or JPG ( max 5 Files )

INSURANCE COVERAGE FOR PLAINTIFF

Name of Carrier

Policy Number (if known)

Name of Any Agent You've Spoken With Since Injury

IMPORTANT: Has Anyone From an Insurance Company Contacted You About This Claim? Please List Their Name and Phone Number:

Have You Signed Any Authorizations to Release Information to Anyone? If so, Identify and Describe:

INSURANCE COVERAGE FOR DEFENDANT

Name of Defendant Carrier (if known)

Agent's Name, Address and Phone (if known)

MEDICAL INFORMATION

Please Describe in Detail the Injuries of All Persons (Attach a Separate File if Necessary)

Injury Document Upload (Optional)

Upload Up To 3 Files

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 3 Files )

Did Anyone Go to the Hospital? If so, Which Hospital?

Were You Taken by Ambulance? (Which Company?)

Were X-rays Taken?

LIST ALL DOCTORS, CHIROPRACTORS, HOSPITALS, ETC. SEEN (Attach a Separate File if Necessary):

Doctor/Chiropractor/Hospital Upload Information (Optional)

Upload Up To 5 Files

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 5 Files )

PRESCRIPTIONS

Name and Location of Pharmacy Where Prescriptions are Filled?

DAMAGES

How Have Your Injuries Changed Your Lifestyle (Attach Separate Sheet if Necessary)

Upload - How Have Your Injuries Changed Your Lifestyle (Optional)

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Describe Any Pain & Suffering That You've Experienced

Loss of Consortium (Relationship With Spouse, Children, Others)

Have any Sports or Social Activities Been Affected?

Job Duties That Have Been Affected, Including Time off From Work or School

Household Chores That Have Been Affected

How Do You Feel You Have Been Damaged Emotionally by These Injuries?

How Do You Feel You Have Been Damaged Financially by These Injuries?

PROPERTY DAMAGE

What Property Damage Occured? Your Property or Someone Else's?

Was The Property Repaired? Where Were the Repairs Performed?

What Was the Monetary Amount of Damage Done to Your Property?

IMPORTANT: Please Provide Any Receipts or Damage Estimates in Your Possession. Upload up to 5 files below. Were There Any Witnesses to the Injury Scene That You Know of? Please List Their Name and Contact Information if You Know, or Describe the Witness(es) as Best You Can:

Receipt/Damage Estimate

Upload Up To 5 Files

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 5 Files )

Is There Anything Else That You Would Like to Discuss or That You Believe We Should Know About You or Your Case?

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