Clone of FINAL - Personal Injury/Wrongful Death Information Sheet

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Password*

Client Questionnaire

PLEASE FILL THIS OUT PRIOR TO YOUR FIRST MEETING WITH YOUR ATTORNEY
Date

MonthDayYear
We ask every client to fill out this questionnaire at this point in their case. Although some of the information we are requesting may not seem relevant at this time, the information may be needed for us to pursue your case. If you have any questions or concerns, please feel free to contact our office and ask to speak with your case manager.
General Information

(IF DEATH CLAIM, PLEASE COMPLETE AS TO DECEDENT)
Full Legal Name:*
Social Security Number
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Were you married at the time of the incident?

YesNo
Spouse's Name
At the time of the incident, were you suffering from any medical or physical infirmity, disability, or sickness? If so, please list the nature of each.
Were you employed at the time of the incident?

YesNo
If so, please provide the following:
Company Name
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you lost any income due to this incident?

YesNo
If so, how much?
Number of Days Missed
Please provide my office with check stubs, doctor notes for missing work, etc.
If you have lost income, please list your employment history for the last 3 years, including estimated dates of employment, rates of pay, and position.
Other than medical bills and/or loss of income, do you have any other bills related to this incident? (i.e. vehicle repair bill, prescription purchases, help with housework, etc.)

Documents needed at this time:
If you have not already provided a copy of your Health Insurance Card, please include one with this questionnaire.
If you have not already provided them to our office, please include color copies of any photographs of your injuries, the scene of the incident, and/or any property damage involved in the incident.
Date*

MonthDayYear
Signature*
Should be Empty:

Please enter your Client Portal password.

Client Questionnaire

General Information

Documents needed at this time:

If you have not already provided a copy of your Health Insurance Card, please include one with this questionnaire.

If you have not already provided them to our office, please include color copies of any photographs of your injuries, the scene of the incident, and/or any property damage involved in the incident.