1. Client Information
Full Name
*
Date of birth
*
Email
*
Address
Street Address
*
City
*
State
*
Country
*
Country
Postal Code
*
Phone
*
Emergency Contact Name
*
Emergency Contact Email
*
2. Incident Details
Date of Incident
*
Location of Incident
*
Type of Incident (HIGHLIGHT all that apply)
*
Car Accident
Slip and Fall / Trip and Fall
Workplace Accident
Workplace Accident
Medical Malpractice
Product Liability
Other:
3. Injuries Sustained
Body parts injured:
*
Did client seek medical treatment?
*
Yes
No
Date of first treatment
*
Hospital/Clinic/Doctor’s Name
*
Ongoing treatment?
*
Yes
No
Current condition:
*
4. Parties Involved
Defendant/At-Fault Party
*
Defendant’s Contact Information (if known)
Insurance Information (defendant’s insurance company, policy number if available)
Police Report filed?
*
Yes
No
Report Number (if available)
5. Client’s Insurance Information
Health Insurance Provider
*
Auto Insurance Provider (if applicable)
Policy Number(s)
*
MedPay Coverage
Yes
No
6. Damages and Losses
Medical Bills to Date
*
Property Damage (vehicle, personal belongings)
*
Lost Wages (dates missed, employer contact)
*
Out-of-pocket expenses
*
Pain & Suffering (impact on daily life)
*
7. Prior Claims/Medical History
Has the client had prior accidents or injuries?
Yes
No
Pre-existing medical conditions relevant to injury?
Yes
No
Prior lawsuits/claims filed?
Yes
No
8. Goals and Expectations
What outcome is the client seeking?
*
(medical bills paid, lost wages, pain & suffering damages, etc.)
9. Additional Notes
Anything else relevant to the case