Personal Injury Case Evaluation

1. What is your full name, address, telephone number, and email address.

*Name:

*Address:

*City:

*State:
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*Zip:

*Home Phone:

*E-mail address:

*Date of birth:

2. If you are not the injured indivdual, please state your relationship to the injured individual and the injured individual's full name address, telephone number, email address and date of birth.

Relationship:

Injured person's full name:

Address:

City:

State:
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Zip:

Telephone number:

E-mail address:

3. Please briefly describe the incident or accident that you are calling about? What happened?

4. Where did the incident happen and on what date?

Where:

What date:

5. What injuries did the injured individual suffer solely as a result of the incident.? Be as detailed as possible.

6. Did the injured individual see a physician or healthcare provider with twenty four (24) hours of the incident?
Yes  No 

7. Has the injured individual ever before sustained similar injuries.
Yes  No 

8. Is the injured individual still seeing a physician?
Yes  No 

9. Does the injured individual have insurance which is paying medical bills? If so, with what carrier?
Yes  No 

Carrier

10. Has the injured individual:
A. Lost time from work because of the injuries;
B. Lost the ability to work because of the injuries.

11. If this was a motor vehicle accident:
A. Was the injured individual wearing a seatbelt;
B. Has the damage to the vehicle been repaired.

12. Who do you believe is responsible for the incident and the injuries the injured individual has suffered and why?

13. If you believe a product caused the incident or the injuries suffered by the injured individual, please identify the product and please tell us if you still possess the product.

14. Were there eywitnesses to the incident and if so, do you have their names and addresses?
Yes  No 

15. Was the incident investigated by the law enforcement, and if so, do you have a copy of the investigation report?
Investigated
Yes  No 

Copy of investigative report
Yes  No 

16. Do you have photographs of the incident or the injured individual?
Yes  No 

17. Has the injured individual previously retained an attorney on this matter?
Yes  No