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Attorney Injury Intake Questionnaire

Life for an injury victim often becomes much more difficult after the injury. The extent of injuries is not always clear until days or months after an auto accident. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with:

  • Doctors
  • Insurance companies
  • Attorneys

Also, injury victims may need to provide documentation to their employer to justify (or get reimbursed for) recovery time.

Each party involved will ask the victim or a representative to show documentation. If you are an injury victim planning to file a claim, your attorney will ask several detailed questions. Preparing will make the process much easier.

Fill out the form below to prepare for most of these questions.

Name _____________________________________________

Date of birth ____/____/____

Social security number _____-____-_______

Address ____________________________________________

___________________________________________________

___________________________________________________

Home phone (_____) ______-________

Work phone (_____) ______-________

Mobile phone (_____) ______-________

E-mail address ____________________

Best method to reach you ________________________

Best times to reach you __________________________

Married ____ Single ____ Divorced ____

Number of children ____

If married, spouse's name _________________________

On what date did your injury occur? ____/____/____

Where did your injury occur? City _____________ State _____

How did your injury occur?

__ Aircraft accident

__ Animal bite or attack

__ Assault and battery

__ Defective premises

__ Defective product

__ Police negligence or abuse

__ Medical malpractice

__ Motor vehicle accident

__ Slip or trip and fall

__ Water-related accident

Other ______________________

Describe how your injury happened.

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Who do you believe caused or is responsible for your injury, and why?

__________________________________________________________

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Describe your injuries.

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List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers.

__________________________________________________________

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Total medical expenses to date for your injuries: $________________

Total medical expenses you expect to have in the future: $________________

List the names, addresses, and telephone numbers of all insurance companies involved (including automobile insurers, health insurers, disability insurers, homeowner's insurers, etc.).

_____________________________________________________

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Have you lost income due to your injuries? Yes __ No__

If yes, the amount of lost income $_________

Income before injury $__________ per ___________

Income after injury $__________ per ___________

Employer __________________________________________

Position ___________________________________________

Employer's address _____________________________________

____________________________________________________

____________________________________________________

Employer's telephone number (_____) _______-________

Are you working? Yes ___ No ___

Expect to return to work on ___/___/___

Will not return to work ___

Are you in pain? If so, describe.

__________________________________________________________

__________________________________________________________

__________________________________________________________

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Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.)

__________________________________________________________

__________________________________________________________

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If married, has your spouse experienced any losses as a result of your injury? If so, describe.

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List the names, addresses, and phone numbers of any possible witnesses.

__________________________________________________________

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Have you consulted any other attorneys for your case?

Yes ____ No ____

If yes, provide the attorneys' name(s), the firm name(s), the address(es), and the telephone number(s).

__________________________________________________________

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__________________________________________________________

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Is your relationship with the attorney ongoing?

Yes ____ No ____

Has an attorney declined to represent you in this matter?

Yes ____ No ____

If yes, why?

__________________________________________________________

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__________________________________________________________

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Questions you have about your case:

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Statute of Limitations

A statute of limitations is a critical personal injury law concept. Anyone considering a personal injury claim must understand it.

The statute of limitations is a countdown. From the date of your accident injury, it's the time new clients have to begin legal proceedings against the party you believe is at fault.

This period can vary considerably. It's typically from one to six years, depending on the state and the specifics of the injury. For example, claims related to medical malpractice might have a different statute of limitations than a claim arising from a motor vehicle accident.

You must file your claim within this timeframe. Otherwise, regardless of the merit of your case, the court could dismiss it outright.

A personal injury attorney will be familiar with these time limits. They will ensure that your claim gets filed on time.

Wrongful Death

If a person dies as a result of someone else's negligence or intentional actions, the person's surviving relatives can file a wrongful death lawsuit. This is a complex area of law, and the rules about who can file a wrongful death claim vary by state.

In some states, only immediate family members can file a claim. In others, extended family or even financial dependents can make a claim.

These claims can seek compensation for:

  • Medical and funeral expenses
  • Lost future earnings of the deceased
  • Emotional suffering
  • Loss of companionship or parental guidance

Workers' Compensation

If you get injured at work, you need to understand the role of workers' compensation. This insurance program is mandatory for most employers, offering benefits to workers who sustain job-related injuries or illnesses.

The benefits can include coverage for:

  • Medical expenses
  • Replacement income for lost wages
  • Compensation for any permanent injuries
  • Vocational rehabilitation if you can't return to your previous job

Unlike in a personal injury lawsuit, workers don't have to prove that their employer was at fault for the injury to claim these benefits. But they must meet specific reporting and filing deadlines. A knowledgeable attorney can help.

Recovering Lost Wages and Medical Treatment

After a personal injury, your finances can take a significant hit. You may need to take time off work, often unpaid, to recover. Meanwhile, medical bills will start piling up. A personal injury claim aims to "make you whole" by recovering these lost wages and medical costs. To maximize your compensation, keep careful documentation of all:

  • Lost workdays
  • Medical treatments
  • Related expenses

Insurance Information

Multiple insurance companies will likely get involved in your personal injury case. This could include:

  • Your own health or auto insurance
  • The at-fault party's insurer
  • Your disability or homeowner's insurance

Each of these companies has different procedures for reporting injuries and filing claims. Report the accident to all applicable insurers. Be careful not to make any statements that could harm your claim. An experienced personal injury lawyer can help manage these communications, ensuring you follow all requirements and protect your rights.

Property Damage

If you're in an accident that causes personal injury, there may also be property damage. This is particularly true in car accidents. Your vehicle might need repairs or even replacement. Documenting this damage — through photos, repair estimates, and related bills — is crucial. This documentation can form part of your claim, helping ensure you get compensated for the full extent of your losses.

Get Professional Legal Advice From a Car Accident Lawyer Today

Understanding who's liable for what in a personal injury case is complex. Failing to get such an understanding could prove costly for a client's case. An initial consultation with an accident attorney will help you learn about the relevant laws in your state.

If you've suffered an injury and need to recover compensation for your medical care and other expenses, fill out this client intake form. Then, follow up with a lawyer as soon as possible.

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