Client Questionnaire


    The Accident

    DaylightDark


    YesNo


    YesNo


    YesNo


    Diagram of Accident

    Please draw a detailed diagram of the accident scene and vehicles to the best of your ability.


    Witnesses

    Names and phone number of any witnesses or others that may be of assistance to your claims.


    Vehicles Involved in the Accident


    YesNo


    Injuries and Damages from this Accident


    YesNo


    Medical Treatment and Hospitalizations


    YesNo

    Please list all Medical Providers who have seen or treated you as a result of this accident:


    YesNo


    YesNo


    "Out-Of-Pocket" Expenses or Obligations Resulting from this accident


    **NOTE: PLEASE KEEP ALL BILLS AND RECEIPTS AND
    TURN THEM OVER TO YOUR ATTORNEY. **


    Insurance and Workers' Compensation


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    Workers' Compensation


    YesNo


    YesNo


    Social Security or Medicare


    YesNo


    YesNo


    Educational Background


    Work Background


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    Military Background


    YesNo


    YesNo


    YesNo


    Prior Claims and Lawsuits

    List every claim you have ever made for personal injury or property damage and give details. This includes claims under state workers’ compensation laws, Railroad Sickness Benefits, and the Longshore and Harbor Workers’ Compensation Act. If you have made no claims and filed no lawsuits, state “none.”

    **Having previous claims or injuries will not necessarily damage any current claims, it is the denial of them (or failing to disclose) that can harm your potential claim.**


    YesNo



    YesNo


    Prior Accidents and Injuries

    Please list any prior incident, whether it resulted in a claim for damages or not, stating the date, place, and nature of the accident, and the extent of your injuries. If you have had no prior accidents or injuries, state “none.”

    **Having previous accidents or claims will not necessarily damage any current claims, it is the denial of them (or failing to disclose) that can harm your potential claim.**


    YesNo



    YesNo


    Accidents Or Injuries After This Accident


    YesNo


    YesNo