Premise Liability | Slip & Fall
Staff Member Intaking:
*
LO
BB
LA
MM
TW
SC
TC
TA
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
Country
Postal code
How Did You Hear About Us
*
Billboard
Driving By
Building
Word Of Mouth
Facebook
Google
Referral
TV
Website
Other
Prior Client
If other, where did you hear about us?
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
FACTS OF INCIDENT:
Date of Incident:
Time of Incident:
Location of Incident City & State:
Description of Incident:
Name of Property Owner where injury occurred (if known):
Type of Property:
Business
Home
Apartment/Multi Family
Other
Did you report the incident to anyone:
Yes
No
If yes, who did you report the incident to:
Statements made by anyone:
Were police called to the scene?
Yes
No
If yes, name of reporting agency and Report number:
Tickets Issued?
Yes
No
Were there any witnesses to the Incident:
Yes
No
If yes, please provide names and contact information of any witnesses known:
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:
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:
Have you been contacted by any insurance company relative to the incident?
Yes
No
If yes, provide name of insurance company and any contact information and/or claim number received:
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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