Motor Vehicle Collision - Wrongful Death

Caller Name (if not injured party):

Caller Phone Number:

Caller Email:

Relationship Of Caller To The Injured:

Potential client Info

Full Name Of Potential Client *

Prefix *

Mr.

Ms.

Phone *

Email

No Email Provided

No Email

Date of birth

Address

Street Address

City

State

Country

Postal code

Okay To Text? *

Yes

No

Okay To Email? *

Yes

No

Have You Consulted With Any Other Law Firms?

Yes

No

If Yes, who?

If Yes, Are You Currently Represented By An Attorney For This Matter?

Yes

No

If Yes, Who Currently Represents you?

If we are not able to assist, may we send your information to a referral source?

Yes

No

DECEDENT’S INFORMATON:

Decedent Name:

Caller's relationship to decedent:

Decedent DOB:

Decedent date of death:

FACTS OF INCIDENT

Date of incident:

Time of accident:

Location of incident:

Description of incident:

Statements made by other driver:

Were police called to the scene?

Yes

No

If yes, name of reporting agency:

Ticket issued?

Yes

No

Decedent's role:

Driver

Passenger

Pedestrian

Unkown

Any other individuals in the vehicle with decedent?

Yes

No

Unkown

Were there any witnesses to the collision:

Yes

No

Unkown

If yes, please provide names and contact information of any witnesses known:

Was Decedent the owner of the vehicle involved?

Yes

No

Unkown

N/A

If no, who owned the vehicle and their relationship to decedent:

INJURIES AND MEDICAL TREATMENT

List ALL Injuries and/or Cause of Death (from Death Certificate):

Did Decedent receive any medical treatment prior to passing?

Yes

No

If yes, where:

INSURANCE INFORMATION

List the names and auto insurance information of all parties involved:

At-Fault Party Full Name: awd

At-Fault Insurance company name:

At-FaultIns Policy OR Claim Number:

Decedent's Full name of insured:

Decedent's Insurance company name:

Decedent's Insurance Policy OR Claim Number:

Has there been any communication with any insurance company regarding this accident?

Yes

No

If Yes, who?

POTENTIAL BENEFICIARIES

List of surviving Class 1 family members (mom, dad, child(ren), and/or spouse):

Any children under the age of 18?

Yes

No

EMPLOYMENT

Was Decedent employed at the time of the incident? awd

Yes

No

If yes, employer and occupation:

Call Notes

General Notes During Intake:

Privacy Policy | Terms of Service