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What type of case is this?
Your First Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
Middle Name
Last Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
For example, Jr., III, Esq.
Thank you for sharing with us how you found MattLaw.
Please tell us the name of the Attorney who referred you to MattLaw
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This is the address where we will mail any documents relating to the case.
What is your Facebook web address? Example https://Facebook.com/MattLaw
Enter the person's birth date
Person's Age
Please enter the name and any other information of who we can contact if for any reason we cannot contact you.
End of contact information for Main Contact, beginning of contact for other person who is injured or deceased
This is when the Injured Person can't represent themselves for reasons such as they are a child, or they are incompetent and can't make decisions on their own, or they are deceased.
Your First Name. This is where you enter the name of the Injured Person or deceased victim.
Middle Name
Last Name. This is where you enter the name of the Injured Person, child or deceased victim.
For example, Jr., III, Esq.
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Where does the injured person reside.
If there is additional information about the injured person that did not fit in the boxes above, add that information here please.
Beginning of Work History and Loss of Earnings for the Injured Person.
Where do they work
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How much are you paid?
How long have you been unemployed?
What was your last employment before becoming unemployed.
Workers Compensation
Workers Compensation
What year did you retire?
What year did you become disabled?
Where are you attending school?
If there is additional information add it here.
End of Client Work History --- DATE OF LOSS
This is the end of the Main Client Contact information, and if they are the Parent of an injured child, or the PR of a deceased person, or a Guardian of an incompetent, then we gather the injured person's basic information here.
Are we being asked to represent more than one person for the same accident? If Yes, then we will gather their names and other information later in this questionnaire.
Any other information about companion cases goes here.
Beginning of LIABILITY
Select the County where the accident happened
Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
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Describe what you saw before the impact.
Did your car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Did the car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Describe what was wrong with the vehicle that may have had something to do with the collision.
Was anyone intoxicated during the accident?
Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the at fault person do? Why are they negligent?
We want to know what admissions they may have made where they admitted fault in some way.
Who were the admissions made to?
Admissions like, I did not see you. It is all my fault. I missed my turn. I don't know what happened. My brakes have been bad for a while.
Witness Identification who may be a witness?
We are collecting the names of Eye Witnesses, and or Companions to your case.
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What is the name of the first eye witness who you have not told us about already?
What is the name of the first eye witness who you have not told us about already?
How can we get in touch with any eye witnesses so we can ask them what they remember about this.
End of ID of people in Clients car / Beginning of description of the Incident
Enter what their ticket was for. For example, following too closely
If you got a traffic citation, what was it for?
Which vehicles left skid marks, which vehicles left gouges in the road, how long were they, where were they located?
EVIDENCE Section:
Evidence
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
Tell us about anything else we might want to photograph, or obtain to help prove your case?
End of Evidence and photographs. Beginning of Injuries
Tell us the name of the Fire Rescue department so we can order the records.
If they were admitted to the hospital, when did they get discharged? If they are still in the hospital, put a date in that they expect to go home.
What other injuries or physical or psychological problems are you having that you relate to this crash that you have not checked above.
Please tell us all the doctors, chiropractors, X-ray, MRI facilities that you have been to after this crash. Name, city, location, so that we can order all of your medical records. If you have not seen anyone yet, just type in NONE.
Injuries
Please list the medications that you have been prescribed, the name of the medication, the strength of the medication and where you got the prescription filed.
Example: Flexeril, 80mg as needed, filed at CVS pharmacy on Waters Avenue in Tampa. Or, None, if you don't have any prescriptions.
Were you taking any medications on a regular basis, such as for a heart condition, or arthritis, blood pressure, diabetes, anything at all. If none, just type in NONE.
We may want to order these records so that we can make sure your treating doctors know about your prior conditions so they can factor them into your health care plan.
Please tell us each and every hospital you have been seen in over the past 10 years. Including short visits like an Emergency room and released, to long term admission as a patient.
Have you ever made any sort of claim before this one? Like workers compensation, car accident, slip and fall, dog bite, class action claim where you were a party?
We need to know about any and all claims you may have had so we can get those records and let your doctors know about your prior injuries and claims.
Have you ever seen a chiropractor, even for one visit before this incident?
We need the name, address and approximate date that you saw chiropractors before this accident. Also, it may be a good idea for you to return to them to be seen as a Before and After Doctor to help prove your case.
Have you ever seen a psychiatrist, psychologist, or been Baker Acted before this incident?
We need the name, address and approximate date that you saw any mental health professionals before this accident.
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Have you been given a work disability slip from anyone because of your injuries from this car crash?
Help us figure out how much work you will miss because of your injuries from this incident. You can say in hours, days, weeks or years.
Please give us the name and location of the doctor that has taken you off of work. We need to order your records
Please calculate as best you can what amount of money you have lost so far as a result of this crash?
Beginning of Clients UM and Other Insurance coverage
Are any of your policies from out of the State of Florida? We need to know this so that if you have an out of state policy, the coverage's may be different that typically required by Florida Law.
If you don't have a Florida insurance policy, which state is the policy from?
If you know the Med Pay policy limits please indicate this, if you don't know, put Unknown
What are the limits on your UM policy? If you don't know or are not sure, just put unknown.
Stacked UM coverage gives you more benefits. Also, they can be stacked even if they are with different insurance companies, and sometimes even on some motorcycle policies.
What is the total number of motor vehicles that you own that may provide UM coverage to you?
What is the total number of motor vehicles that the Injured Person owned on the day of the crash that might provide UM coverage to them?
Do you happen to have different insurance companies for different vehicles? If so, we want to contact them all and find out if there are any other UM policies to cover your losses.
Provide your Umbrella Policy Number if known, if you don't know, enter Unknown
If you have Stacked UM Umbrella Insurance please let us know.
Please give us the name and phone number of your Insurance Agent so we can see what other coverage's you might have to protect you and your family.
Please give us the name and phone number of the Injured Person's Insurance Agent so we can see what other coverage's might be available to protect them.
End of UM and Other Insurance coverage
PIP Questions for Main Client
Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage.
Your PIP Insurance will pay your medical bill and wage benefits
Because you owned a car and it was insured, you use your own PIP insurance. This is why it is called "No Fault" insurance.
If their answer is YES, they are out of luck, no PIP. If their answer is No, the get PIP from their resident relative or the vehicle they were occupying.
You probably have No PIP insurance to pay your medical bills or lost wages.
If you owned a car that was being operated on Florida roads and did not have insurance on that car, then most likely your health insurance or disability insurance will have to pay your medical bills and lost income, unless we recover them from the at fault person.
Did you live with any relatives at the time of the crash? If you did and your relative had car insurance then you may be covered under their PIP policy. Resident relative includes parents, spouse, child, brother, sister, grandparent. If you did live with any resident relatives, then you get Pro-rata PIP insurance from the various resident relative policies in your household.
Your Relatives PIP Insurance will pay your medical bill and wage benefits.
Because your car was either inoperable, or out of state, and you lived with a resident relative, you get your relative's PIP insurance.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
You get PIP insurance from the owner of the car you were in at the time of the crash.
Because you did not own a car, and did not live with a resident relative, you get the PIP insurance from the car you were in.
Beginning of PIP Questions for the Injured Person
Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage for this car accident.
The Injured Person's PIP Insurance will pay their medical bill and wage benefits.
Because the Injured Person owned a car and it was insured, they use their own PIP insurance. This is why it is called "No Fault" insurance.
If their answer is YES, they are out of luck, no PIP. If their answer is No, the get PIP from their resident relative or the vehicle they were occupying.
The Injured Person's has no PIP Insurance to pay their medical bill and wage benefits.
Because the Injured Person owned a car and it was not insured, and it should have been insured they have no insurance to pay their medical bills or lost wages unless we collect them from the at fault party.
Did the Injured Person live with any relatives at the time of the crash? If they did and their relative(s) had car insurance then they may be covered under their relative's PIP policy. Resident relative includes parents, spouse, child, brother, sister, grandparent. If they did live with a resident relative(s), then they get Pro-rata PIP insurance from the various resident relative policies in their household.
The Injured Person's Relative's PIP Insurance will pay their medical bill and wage benefits.
Because the Injured Person's car was either inoperable, or out of state, and they lived with a resident relative, they get their relative's PIP insurance.
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
The Injured Person get PIP insurance from the owner of the car they were in at the time of the crash.
Because the Injured Person did not own a car, and did not live with a resident relative, they get the PIP insurance from the car they were in.
Enter the claim number or if you don't have one enter Unknown.
We need the name of the rental company so that we can find out what insurance was taken out that may protect you.
If you were in a rented car, did the renter of the car take out any insurance coverage through the rental car company, or credit card?
Matt, look at other questions that may go with this question.
End of PIP beginning of At Fault Insurance
This is where we start recording the At Fault Insurance Company information.
First Name of the At Fault Driver.
Middle Name
Last Name of the At Fault Driver.
For example, Jr., III, Esq.
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Name of the At Fault Insurance Company
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
First Name of the At Fault vehicle OWNER. If the owner is a company, just enter the name of the company that owned the vehicle that caused injuries.
Middle Name
Last Name of the At Fault Driver.
For example, Jr., III, Esq.
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Name of the Insurance Company for the Owner of the vehicle that was at fault.
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Who was the driver working for when he caused the crash? We will sue his employer also.
Explain why you think the bad driver was working or running an errand for someone else when the crash occurred? We want to know to seek additional insurance coverages for you.
Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information
Do you have any type of Health Insurance?
This date is on your health insurance card and it tell us when your coverage first began.
Do you have any type of Medicare Insurance or supplements? Medicare is generally for people over the age of 65, or if the person is on Social Security Disability.
What is the name of Part A
We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part A has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part B Medicare Insurance Company
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part B has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part C Medicare Insurance Company
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part C has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part D Medicare Insurance Company
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part D has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
This date is on your Medicade insurance card and it tell us when your coverage first began.
We need to know if Medicaid has paid any money to help with your care as a result of this incident?
Medicaid is only available to poor people, not related to age.
Wellcare is available to children and adults of low income, and may not have Medicare Parts A, B or C. We need to know what bills if any Wellcare has paid.
It might be called just Wellcare, and it may be managed by another company. We need the company name.
This date is on your Medicade insurance card and it tell us when your coverage first began.
We need to know if Wellcare has paid any money to help with your care as a result of this incident?
Wellcare is only available to poor people, not related to age.
What is their address or contact information for Medicaid?
If you have any disability insurance that may pay you benefits please let us know about them.
Did you receive any payments for short term or long term disability? If so, we need to contact your disability insurance companies to know what their lien is.
Any notes about any sort of collateral source, which is some other company paying any sort of related bills for lost wages or medical treatments. AFLAC would be included here as well. Get copies of any insurance cards
End of Health Insurance
Beginning of Property Damage MVA
What kind of car was damaged in this crash?
What color is your car
Is your car or bike still accruing storage charges?
End of Property Damage MVA
Recorded Statements:
We want copies of any recorded statement you may have made, or any court appearance you have made. Please tell us when you gave the recording and to whom?
Beginning of Client Assessment and lifestyle
Why have you not filed your taxes? Maybe you were paid cash? Maybe you did not make enough, maybe you did not know how to file. What ever the reason, please let us know.
Please tell us about any and all arrests
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
shoplifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Filing Bankruptcy may mess up your injury case, but if we know about your filing for bankruptcy before you file, it will help you recover the money, rather than your creditors.
We would like to know if you have sought legal representation before calling us?
If you have a good reason to fire your attorney that has an effect on their ability to recover fees for the work they did.
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We can send him a letter on your behalf terminating him, but we need his address to obtain a copy of your file and send him a letter discharging him from your case.
We need to collect all of your records and often times the first or second attorney has some investigative records that we might need to help prove your case.
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Are you bringing any other personal injury claims other than this one?
Do you have any other pending pclaims going on now?"
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Please let us know the names, addresses and types of prior injury claim attorneys, workers compensation attorneys or any other notes that may help us with your case. What is the status of their representation of you now?
Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.