Premise Liability | Slip & Fall

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

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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