Auto Intake Form

Staff Member Intaking: *

LO

EH

LA

AG

MM

TW

SC

Caller Name (if not injured party):

Caller Phone Number:

Caller Email:

Relationship Of Caller To The Injured:

Potential client Info

Full Name *

Prefix *

Mr.

Ms.

Phone *

Email

No Email Provided

No Email

Date of birth

Address

Street Address

City

State

Postal code

Okay To Text? *

Yes

No

Okay To Email? *

Yes

No

How Did You Hear About Us *

Billboard

Driving By

Building

Word Of Mouth

Facebook

Google

Referral

TV

Website

Other

Prior Client

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

Facts of incident

Date Of Incident

Time of incident?

Location of Accident (Street/Intersection/City/State):

Description of Collision

Statement made by other driver

Where police called to the scene?

Yes

No

If yes, name of reporting agency and report number

Tickets Issued?

Yes

No

Your role?

Driver

Passenger

Pedestrian

Any other individuals in the vehicle with you?

Yes

No

N/A

Were you the owner of the vehicle involved?

Yes

No

N/A

If no, who owned the vehicle and their relationship with you?

Injuries and medical treatment:

List ALL Injuries

Were you transported by ambulance?

Yes

No

Were you evaluated in ER on date of crash?

Yes

No

Medical treatment received (i.e. hospital, doctor visits, physical therapy, chiro)::

Are you still receiving treatment?

Yes

No

If yes, please describe ongoing treatment/future appointments:

Do you have any previous injuries or medical conditions that may relate to this claim?

Yes

No

Insurance Information

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

At-Fault Party full name:

Insurance Company Name:

Ins Policy OR Claim Number:

Your Auto Insurance information:

Full Name of Insured:

Client Ins Company Name:

Client Ins Policy OR Claim Number:

Lost Wages

Have you been out of work for this accident?

Yes

No

If yes, approximate time out of work:

Employer:

Occupation:

Call Notes

General Notes During Intake:

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