Attorney Intake Form: Airline Personal Injuries
Created by FindLaw's team of legal writers and editors | Last updated December 03, 2018
People are killed or seriously injured in airplane crashes every year. In other situations, an airline passenger may twist his or her back trying to put a piece of luggage in an overhead bin, or be burned by spilled coffee from the service cart during a particularly rough patch of turbulence. If you have been injured while on an airplane, you might retain the services of an attorney. This intake form may help answer those questions.
Intake Form: Airline Personal Injuries
Name _____________________________
Date of Birth _______________________
Social Security Number __________________
Address, Including County:
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Length of Time at that Address: _______ years _______ months
Previous Address(es) (for last 10 years):
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Home Telephone Number: ____________________
Work Telephone Number: ____________________
Facsimile Number: ____________________
E-mail Address: ____________________
Former Name(s): ____________________
Current Employer: ____________________
Position: ____________________
Employer’s Address:
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Length of Time with Employer: _______ years
Previous Employer(s) (for last 10 years):
______________________________ ______________________________
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Gross Monthly Income: $_________________
Marital Status: __________________________
Previous Marriage(s): Yes ____ No ____ How Ended?_________________
Children
Name Date of Birth Living in home?
_______________ _________ _______________
_______________ _________ _______________
_______________ _________ _______________
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Dates of Travel: _________________________________
Purpose for Travel: _______________________________
Travel Agency Used: _____________________________Yes/No
Name ___________________________________
Address __________________________________
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Airline: _________________________________________
Flight Number: ___________________________________
Departure City: ___________________________________
Arrival City: _____________________________________
Date of Injury: ____________________________________
Approximate Time of Injury: ________________________
Description of How Injury Occurred:
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Names and Addresses of Witnesses to Injury, If Known:
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Injury Reported to Airline ___________Yes/No
When________________________________________
To Whom _____________________________________
Additional Contact with Airline __________________________________________________________________
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Description of Immediate Medical Attention Received Including Names and Locations of Providers:
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Description of Subsequent Medical Attention Received Including Names and Locations of Providers:
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Current Medical Condition:
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Any Surgeries Performed or Scheduled As a Result of Injury:
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Previous Medical History:
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Any History of Similar/Same Injuries:
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Does Injury Prohibit Performance of Any Daily Living Activities (Examples: Can you brush your hair? Dress yourself? Drive a Car?)
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Time Lost From Work Since Injury_______________Yes/No
Amount of Time Lost Including Specific Dates, If Known:
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Hobbies/Interests:
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Does Injury Prevent You From Engaging In These Hobbies/Interests?__________ Yes/No
Explain ___________________________________________________________
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Other Important Information:
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Questions to Ask My Attorney:
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Get Legal Help with Your Airline Personal Injuries
Airline injuries can have series implications for victims, including extensive recovery time spent away from work. An injury lawsuit can allow you to recover compensation for your medical expenses, lost wages, and pain and suffering. However, navigating an airline injury suit is a complicated task. The first step is to learn more about your claim, which you can do by discussing your case with a skilled personal injury attorney near you.
Next Steps
Contact a qualified personal injury attorney to make sure your rights are protected.