New Case Online Intake Form for MattLaw

Type of Case*
What type of case is this?
Main Contact's Name*
Salutation First Middle Last Jr., III, etc.
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.
How did you find the law firm of MattLaw?*
- Advocates United National TV ad
- Billboard
- Book written by Matt Powell
- Facebook
- Former Client
- A Friend told me to call you
- Google Search
- Lets Ask A Lawyer Show
- A lawyer referred me to you
- Linked In
- Motorcycle Event
- Twitter
- TV Commercial MattLaw
- Vietnamese Magazine
- Walk In
- YouTube
Thank you for sharing with us how you found MattLaw.
Name of Friend who referred you to MattLaw*
First Last
Name of Attorney who referred you to MattLaw*
First Last
Please tell us the name of the Attorney who referred you to MattLaw
Main Contact's Relationship to Injured Person is:*
- I am the Injured Person on behalf of myself
- I am the parent or guardian of the injured minor
- I am the guardian of the incompetent adult
- I am a relative of the injured person
- I am a friend of the injured person acting on their behalf
Are you married?*
- Yes, I am married.
- No, I am not married
Med Mal Alive
What is the Birth Date of the Spouse of our client*
Month
Day
Year

Med Mal Alive We need to know the age of the clients husband or wife to assess the viability of a case if the client were to die before the medical malpractice claim was resolved
How is your spouses health, can they assist in this claim?*
- Excellent and will be a strong witness at a trial
- Fair and may be able to assist in at trial
- Poor and will not be able to attend or offer help at a trial
Med Mal Alive
At the time of the Medical Malpractice, did the decedent have any children age 25 or less?*
- Yes, at the time of my Medical Malpractice, the dead person had at least one child age 25 or less.
- No, the dead person did not have any child age 25 or less at the time of the Medical Malpractice.
Med Mal Wrongful Death If the doctors killed their patient and our client was not married at the time of the malpractice, and our client did not have any children age 25 years or less, then by law, no claim can be made for the wrongful death caused by medical malpractice. A terrible law, you can thank Tort Reform for this. Call your state senator. We regret we can't help you.
How many children under the age of 25 were there on the date of Decedent's death? This includes children born out of wedlock.*
Med Mal Wrongful Death
Name of Child of Decedent under 25 years of age on the date of the malpractice*
First Middle Last
Med Mal Wrongful Death
Date of birth of the child under age 25*
Month
Day
Year

Med Mal Wrongful Death What is the date of birth of the child that can bring a wrongful death medical malpractice case
Name of the Second Child of Decedent under 25 years of age on the date of the malpractice*
First Middle Last
Med Mal Wrongful Death
Date of birth of the Second child under age 25*
Month
Day
Year

Med Mal Wrongful Death What is the date of birth of the child that can bring a wrongful death medical malpractice case
Name of Third Child of Decedent under 25 years of age on the date of the malpractice*
First Middle Last
Med Mal Wrongful Death
Date of birth of the Third child under age 25*
Month
Day
Year

Med Mal Wrongful Death What is the date of birth of the child that can bring a wrongful death medical malpractice case
Name of the Fourth Child of Decedent under 25 years of age on the date of the malpractice*
First Middle Last
Med Mal Wrongful Death
Date of birth of the Fourth child under age 25*
Month
Day
Year

Med Mal Wrongful Death What is the date of birth of the child that can bring a wrongful death medical malpractice case
Notes about the Children who can bring the Med Mal case
Med Mal Wrongful Death We need to contact each and every child that may have a claim as a result of the death of their parent by medical malpractice
Main Contact's Relationship to Deceased Person is:*
- I am the Personal Representative of the Deceased
- I want to be the Personal Representative of the Deceased
Main Contact Address*
Street Address City State Zip

This is the address where we will mail any documents relating to the case.
Cell Phone Main Contact
Enter their Cell Phone Number here
Home Phone Main Contact
Work Phone Main Contact
Email Main Contact
Enter Email Confirm Email
Facebook web address Main Contact

What is your Facebook web address? Example https://Facebook.com/MattLaw
Social Security Number Main Contact
Birth Date of the Main Contact*
Month
Day
Year

Enter the person's birth date
Age Main Contact*
Please enter a number from 0 to 100.
Person's Age
Sex Main Contact*
Emergency or Alternative Contact if we can't find you*
Please enter the name and any other information of who we can contact if for any reason we cannot contact you.
Notes about the client/main contact that does not fit in the boxes above
If there is something else that we should know that pertains to contacting you and it would not fit in the boxes above, add it here. Anything about the case will come later, but just information we need to know that would not fit into the form goes here.
End of contact information for Main Contact, beginning of contact for other person who is injured or deceased
Name of the Injured/Deceased Victim of negligence
Prefix First Middle Last Suffix
This is the name of the Injured Person if they are a minor, an incompetent, or their name if they are deceased. They are not the Legal client because they can't make decisions for themselves, only the Main Client can.
Address of the minor, incapacitated, victim of neglect or deceased: Last Address*
Street Address City State ZIP Code

Where does the injured person reside, or if they are deceased their last address
Sex of the Injured minor, incapacitated or deceased person*
Date of Birth of Injured person*
Month
Day
Year
Date of Birth of Deceased*
Month
Day
Year
Date of Death*
Month
Day
Year
My relationship to the deceased is that I am their*
- Spouse of the deceased
- Parent of the deceased
- Child of the deceased
- Brother or Sister of the deceased
- Other
My relationship to the deceased or injured is described here if they answered Other*
Social Security Number of negligence victim
County where death occurred*
Which county did the death occur in? Where do we get the death certificate?
Do you have a Death Certificate?*
- Yes, I have a certified copy of the Death Certificate.
- Yes, I have a non-certified copy of the Death Certificate.
- No, I do not have a Death Certificate
Name of the Attorney who is handling the Estate*
First Last
We need to contact the attorney for the estate to let them know that we will be bringing this claim, and we need them to keep the estate open until such time as this case is resolved.
Potential Survivors of the Estate*
- Spouse
- Minor child or children
- Adult child or children
- Grand child or grandchildren
- Living Parent(s)
- Siblings - Brother(s) and or Sister(s)
- Adopted child or children
- Illegitamate child or children
Mark all the survivors of the deceased because they must be listed on any law suit. The more the better because it increases the claims we can ask a jury for.
What are the names, ages, and relationship to the deceased and contact information for each of the survivors?*
Please give us the names, ages and relationship to the deceased of minor children, adult children, parents, brothers, sisters or surviving spouse.
Description of Guardianship, who, when where, what court*
If a formal guardianship has been created please provide the details regarding the Court that established the guardianship, dates, etc.
Notes about the injured person that we need to know.
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.
Employment Status of the injured person*
- Employed
- Self Employed
- Homemaker
- Unemployed
- Student
- Retired
- Disabled
- Never Employed
Employer's Name or Company Name*

Where do they work
Work Address*
Street Address City State ZIP Code

Enter the Employer's Address Here
Companies Name that you were working for at the time of the accident*

Workers Compensation
D/B/A Doing Buisness as

Workers Compensation. If the company had a business name other than its legal name, tell us what name they used to do business.
Address of your employer*
Street Address City State ZIP Code

Workers Compensation
Phone number of your employer
Workers Compensation
Federal Tax ID number of your employer
Is your Employers location address different than the above address?*
Workers Compensation
What is the Location Address that is different than the main address*
Street Address Address Line 2 City State ZIP Code

Workers Compensation
Is the place of your accident different than the address of your Employer above?*
Workers Compensation
What is the Address where the accident happened*
Street Address Address Line 2 City State ZIP Code

Workers Compensation
Nature of the business*
What is your Occupation*
Date you were first employed*
Month
Day
Year

Workers Compensation
Are you paid by the:*
How are you paid*
What is your rate of pay*
How much are you paid?
Supervisor's Name where you work*
First Last
Supervisor's Phone or Human Resources Phone
Have you missed any work due to the accident?*
Have you returned to work at all?*
What year did you become unemployed?*

How long have you been unemployed?
What type of employment did you have before becoming unemployed?*

What was your last employment before becoming unemployed.
Last Date the injured worked?*
Month
Day
Year

Workers Compensation
Date you first returned to work*
Month
Day
Year

Workers Compensation
Year of Retirement*

What year did you retire?
Year of Disability*

What year did you become disabled?
Past Job Title before Retirement*
Past Job title if any before becoming disabled*
Where are you a student?*

Where are you attending school?
Notes about employment / retirement / disability
If there is additional information about employment, retirement or disability that would not fit in the boxes, 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.
Date of Incident/ Accident*
Month
Day
Year
Date the accident and/or injury was reported to your employer*
Month
Day
Year

Workers Compensation
Date of Medical Malpractice*
Month
Day
Year

What is the date you believe the malpractice happened?
When did you first think there was malpractice?*

Med Mal Alive When was the first time you thought that some doctor or medical person made a medical mistake causing you harm?
Date of admission to the nursing home facility*
Month
Day
Year

NURSING HOME ABUSE:
When did you first suspect or realize the Nursing Home Neglect?*

NURSING HOME When was the first time you thought that there was nursing home neglect, abuse, or violation of their rights?
Date of discharge from the at fault nursing facility
Month
Day
Year

NURSING HOME ABUSE:
When was the the first time you to called a lawyer about this Malpractice?*

Med Mal Alive
What were the other lawyers Names? What have they told you about this Medical Malpractice Claim?*
Med Mal Alive
Aproximately when was the item that injured you was sold, when did it leave the store or wharehouse?*

PRODUCTS LIABILITY We need to know about what year the product was sold. There are some time limitations on products liability cases and we need a rough estimate of how long the product has been used.
Your best estimate of WHEN the product was manufacutured?*

PRODUCTS LIABILITY Some products have a date of manufacture on them. Others don't. There are some time limitations that may prevent the bringing of a claim depending on how old the item is.
Time of Incident / Accident

: Hours

Minutes

AM/PM
Date of Second Incident / Accident*
Month
Day
Year

If the client has been involved in a second accident, this field will show up and you enter the second DOA here.
Time of Second Incident / Accident

: Hours

Minutes

AM/PM
Was the injured or deceased person the Driver or a Passenger on the bike?*
- The Injured Person who I want you to represent was the Driver of the bike.
- The Injured Person who I want you to repesent was a Passenger on the bike.
MOTORCYCLE AND BICYCLE
Did you have a passenger on your bike?*
- Yes, I had a passenger on my bike at the time of the crash.
- No, I did not have a passenger on my bike at the time of the crash.
MOTORCYCLE AND BICYCLE
I believe the other person on the bike*
- was injured also and wants MattLaw to be their lawyer
- was injured and will get their own laywer
- was not injured and is just an eye witness who will help the case
- was at fault in some way for the accident and I want to make a claim against them
- is too young to know anything about what happened
The name of the Passenger on your Bike*
First Last
MOTORCYCLE OR BICYCLE
Explain what happened and whose fault you believe it to be*
OTHER TYPES OF CLAIMS: Describe in your own words what happened and who you blame for the losses?
Beginning of LIABILITY
Is there any Third Party who is at fault for your injury?*
Workers Compensation If someone other than your co-employees, or employer were at fault, we may be able to bring a claim for your damages against the negligent party unless they were your co-employee or employer.
What crimes were you or the deceased a victim of?*
- Assault
- Battery
- Domestic Violence
- Kidnapping
- Sexaul Assault
- Rape
- Murder
- Other
NEGLIGENT SECURITY
What Other crimes were you a victim of?*
NEGLIGENT SECURITY
Which Law Enforcement Agencies investigated the crime?*

NEGLIGENT SECURITY
What is the Police Report number or numbers?*

NEGLIGENT SECURITY
Do you know who the criminal is?*
- Yes, the identity of the criminal is known.
- No, we do not know who the criminal was.
NEGLIGENT SECURITY
Has the criminal been:*
- Identified
- Arrested
- Convicted
- Plead out
- Found guilty by a jury trial
NEGLIGENT SECURITY
How do you know the criminal*
- They used to be a friend
- They are related to me
- They worked for the company who I was doing business with
- I only know their name from the police
NEGLIGENT SECURITY
What is the Name of the Criminal?*
First Last
NEGLIGENT SECURITY
Describe the location where you were victimized*
- Shopping Mall
- Shopping center
- Parking Lot
- Parking Garage
- Hotel room
- Hotel lobby or common area
- Condominium inside a person's unit
- Condominium common area
- Sports facility
- Gym or work out place
- Public park
- College or university
- Cruise Ship
- Apartment inside a unit
- Apartment common area
- House I own
- House that the criminal lived in
- Business property
- Public place
- Sporting event
- Other
NEGLIGENT SECURITY Select the areas that describe the surroundings where the security was inadequate
Describe the location where the security was inadequate that led to you being victimized*
NEGLIGENT SECURITY For example, it was an unlit parking lot, or the house I rented had poor locks and hinges that were easily opened by a criminal
What third party or business should be held accountable for the attack? Who could have provided better security?*

NEGLIGENT SECURITY When the victim knows the attacker and has a personal relationship and history with them, suing the bad person is usually a waste of time and resources. And unless there is a third party to blame, we often won't take the casel
What did the Property or Business owner do wrong that led to your being a crime victim?*
- Inadequate security guards
- Inadequate lighting
- Poor maintenance
- Poor hiring of employees failing to check them out
- Failing to maintain security cameras
- Failing to install security cameras
- Failing to monitor the security cameras
- Failing to have controlled Gate access
- Failing to landscape so that hiding places were easy for criminals to hide
- Failing to respond to cries for help
- They knew from prior crimes that this was a high crime risk
- Poor locks and hardware on doors, gates, windows or other things to keep crime out
- Other
NEGLIGENT SECURITY Check all that may apply to your attack
Describe what the propery owner did wrong that made it easier for a crime to happen*
NEGLIGENT SECURITY
What makes you think they propery owner knew of the prior crimes?*
NEGLIGENT SECURITY Please describe any prior complaints you may have made or you area aware that others made regarding the poor security and high crime risk.
Who do you think is even partially at fault for you being a victim of this crime?*

NEGLIGENT SECURITY What is the name of the business that you think failed to have adequate security that lead to you being a victim of a crime?
How many times have you been to the place where you were victimized before this attack?*

NEGLIGENT SECURITY How familiar were you with your surroundings where this attack happened?
Describe what happened*
NEGLIGENT SECURITY
What was the defective product that caused the injury*

PRODUCTS LIABILITY
Who is the manufacturor of the product that caused the injury*

PRODUCTS LIABILITY
How did you come in contact with the product?*
- The product was purchased by me or my family
- I was using someone elses item or product
- The product was a gift to me
- I was a guest of another person or business and they provided the product
PRODUCTS LIABILITY
Do you still have the defective product?*
- Yes, I have the defective product that failed and caused the injury.
- No, I do not have the defective product that failed and caused the injury.
PRODUCTS LIABILITY
Do you know what store or who sold the product that injured you?*
- Yes, I know which store sold the defective product that caused the injury or damages.
- No, I do not know who sold the defective product that caused the injury or damages.
PRODUCTS LIABILITY
Who or what company sold the product to the end user?*

PRODUCTS LIABILITY
The following are signs of Nursing Home Abuse and Neglect, mark any that apply*
- Bed Sores
- Unexplained Bruises
- Unexplained falls
- Broken Bones
- Changes in personality of the loved one
- Infections
- Malnutrition
- Dehydration
- Poor hygience
- Medication errors
- Wandering off of the nursing home property
- Other
NURSING HOME ABUSE:
Are there any mental risk factors?
- Dementia
- Alzheimers
NURSING HOME ABUSE:
Statutory Violation of Nursing Homes include:*
- The right to civil and religious liberties
- The right to private and uncensored communications
- The right to have access to a telephone to call others
- The right to have visitation with any person of the residents choice
- The right to have Knowledge of choices about religious functions and participation
- The right to be encouraged and assisted to excercise civil and religious liberties
- The right to have overnight stays outside of the facility
- The right to present grievances on their own behalf
- The right to present grievances for others
- The right to recommend changes in policies and services
- The right to join with other residents for improvements in care
- The right to be free from restraint, interference, coercion, discrimination or reprisal
- The right to have access to ombudsmen and advocates to talk with them
- The right to be active in advocacy or special interest groups
- The right to prompt efforts by facility to resolve resident grievances
- The right to prompt efforts by facility to resolve behavior problems of other residents
- The right to organize or participate in resident groups
- The right to participate in social activities that don't interfere with other residents
- The right to participate in religious activities
- The right to participate in community activities
- The right to request, and examine the most recent inspections of the facility conducted by State or Federal agencies
- The right to see any plan of correction based upon the inspections
- The right to manage their own financial affairs
- The right to delegate financial responsibility to the facility
- If the facility manages money; the right to quarterly accountings of any transactions
- The right to have an accounting for all personal funds of the resident deposited with the facility
- The right upon Admission to the facility to be informed about charges orally and in writing
- The right to be informed about the services available and such charges
- The right to be informed which services are not covered by Social Security
- The right to be adequately informed about their medical condition
- The right to be adequately informed about their proposed treatment.
- The right to be fully informed in advance of any nonemergency changes in care or treatment
- The right to refuse medication
- The right to be informed of the consequences of refusing medication
- The right to refuse treatment
- The right to be informed of the consequences of refusing treatment
- If there is any refusal, the resident's legal representative must be notified
- If there is a refusal of medication or treatment it MUST be marked in the medical chart
- The right to receive adequate and appropriate health care
- The right to recieve adequate and appropriate protective and support services
- The right to mental health services
- The right to planned recreational activities and therapeutic rehab services
- The right to theraputic services consistent with the resident care plan
- The right to review and see the resident health care plan
- The right to privacy in treatment
- The right to privacy in caring for personal needs
- The right to having the room door closed
- The right to have faciliy personnel knock before entering the room
- The right to have security in storing and using personal possessions
- The right to have privacy of the resident's body
- The right to private toileting
- The right to private bathing
- The right to private and confidential medical records
- The right to be treated courteously
- The right to be treated fairly
- The right to be treated with the fullest measure of dignity
- The right to be free from mental abuse
- The right to be free from physical abuse
- The right to be free from corporal punishment
- The right to be free from extended involuntary seclusion
- The right to be free from physical restraints
- The right to be free from chemical restraints
- The right to have the chart documented with any emergency restraint uses
- The right to have any restraint applied by a qualified licnesed Nurse
- The right to see the written reports regarding any restraints
- Restraints may not be used in lieu of staff supervision
- Restraints may not be used for staff convenience
- Restraints may not be used for punishment
- Restraints may not be used for anything other than resident protection or safety
- Right to be discharged only for medical reasons; OR
- Right to be discharged only for welfare of other residents
- Right to be given reasonable notice of no less than 30 days of any involuntary transfer
- Right to not be discharged solely because of the source of payment for care changes
- The right for the resident and family to be consulted in choosing another facility
- The right to select your own phsycian that you pay for
- The right to purchase your pharmaceutical supplies outside the facility
- The right to participate in community-based activity programs
- The right to retain and use personal clothing and possessions
- The right to have copies of the rules and regulations of the facility
- The right to receive notice before a room change is made
- The right to be informed of the bed reservation policy for a hospitalization
- The right to get your bed back after a hospitalization
- The right to challenge a discharage or transfer from the facility
NURSING HOME ABUSE: If you know of any violations of any of these laws, check the box and then explain the violation below.
Name of the Nursing Home facility that was negligent*

NURSING HOME ABUSE: What is the name of the facility that you blame for the abuse or neglect?
Are you still a pateint/ resident in the nursing home?*
NURSING HOME ABUSE:
Who specifically do you think committed malpractice?*
Med Mal Alive Who should be sued? The names of the specific doctors and or health care providers that you want us to go after.
What did the doctors or hospital or health care professionals do that was wrong?*
Med Mal Alive Tell us what you think the health care professional did that fell below the standard of care? What did they do that was negligent. What didn't they do that they should have done?
Describe what happened to you or the injured person caused by negligence?*
Med Mal Alive
What were your medical problems you were being treated for, before the malpractice?*
Med Mal Alive
Your description of the accident*
Workers Compensation
Was your fall a slip and fall or trip and fall?*
- Slip and Fall
- Trip and Fall
- Something fell on me, from a shelf or ceiling
Slip and Fall
County where incident happened*
Select the County where the accident happened
Name of Pharmacy*

Pharmacy Negligence What is the name of the Pharmacy that made the mistake?
Location of the Pharmacy*

Pharmacy Negligence What is the address, or the street and cross street and city where the pharmacy is located.
Check all that apply regading where you were walking*
- I was walking on a sidewalk
- I was crossing the street in a cross walk
- I was crossing the street outside of a cross walk
- I was crossing the street at an intersection with just a traffic light
- I was crossing the street at an intersection with a walk/don't walk light
- I was walking past a driveway
- Other
Pedestrian v MVA accident: We would like to know what the area where you were injured was like regarding sidewalks, cross walks, driveways etc.
Where did your fall happen? What business, their address*
Slip and Fall Please describe with as much detail who the At Fault business is that allowed the condition to occur such that you fell. Name of the business, location, where in the store. With as much detail so I can drive there and find the spot where you fell.
Where was the first point of impact on your body*
- My left side was the first point of impact to my body.
- My right side was the first point of impact to my body.
- I was hit from the back, and my back was the first point of impact to my body.
- I was hit from the front and the front of my body was the first point of impact.
- My head was hit first.
- My hands were the first point of contact.
- My leg was the first point of impact.
- My butt was the first point of impact.
Pedestrian v MVA accident:
What were you doing at the location where you fell?*

Slip and Fall Were you shopping, making a deposit, exercising? What was your purpose you wanted to accomplish before falling?
Were you indoors our outdoors where you fell?*
- I was indoors when I fell
- I was outdoors when I fell
Slip and Fall
Was the weather a part of why you fell down?
The Weather that had something to do with the fall was*
- Rain was what caused my fall
- Water had accumulated and it was slippery
- Rain water was tracked around and led to my fall
- Water had accumulated and hid a hole that led to my fall
Slip and Fall
What were the lighting conditions in the area where you fell?*
- It was dark and hard to see where I fell
- it was dim and difficult to see where I fell
- it was well lighted and easy to see where I fell
Slip and Fall
Do you normally wear glasses or contacts?*
Slip and Fall
Were you wearing your glasses or contact lenses at the time of your fall?*
Slip and Fall
Before you fell, did you see what caused you to fall?*
- Yes, I saw what caused me to fall before I fell.
- No, I did not see what caused me to fall before I fell.
Slip and Fall
After you fell, you probably found out what cuased your fall, please describe what you saw that caused your fall.*
What kind of surface were you walking on when you fell?*
- Tile
- Vinyl Flooring
- Rough cement
- Smooth cement
- Asphault
- Thick carpet
- Short carpet
- Dirt
- Grass
- Metal grating
- Smooth metal
Slip and Fall
What were you doing before the fall*
- Standing still
- Walking
- Running
- Turning around a corner
- Walking up a ramp
- Walking down a ramp
- Walking up steps
- Walking down steps
Slip and Fall
What color was the floor surface?*

Slip and Fall
What did you slip on that caused your fall?*

Slip and Fall
Where was the first point of impact on your body from the fall*
- My butt was the first point of impact from my fall
- My right knee was the first point of impact in my fall.
- My left knee was the first point of impact in my fall.
- Both of my knees hit the ground at the same time when I fell.
- My head was the first point of impact when I fell.
- My hands were the first point of contact
Slip and Fall or Trip and Fall question
Why did you trip and fall, what caused your tripping?*

Slip and Fall For example, a crack in the floor, my shoe got caught in or on something, there was an object on the floor. Help us explain what caused your fall.
What kind of shoes were you wearing when you fell down?*
- None, I was barefoot
- Tennis shoes
- High heels
- Mens' dress shoes
- Leather sandles
- Flip-flops
- Women's short heeled dress shoes
- Work boots
- Casual leather shoes
- Sandles with a heel strap
Slip and Fall
What kind of soles did you have on your shoes?*
- Deep treaded soles
- Treaded soles
- No tread at all
Slip and Fall Describe the bottom of your shoes
What were the soles on your shoes made of?*
- Hard rubber
- Foam rubber
- Leather
Slip and Fall Describe the material the soles of your shoes were made out of
Location of the accident*

Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
Where was the injured person sitting in the car?*
- The injured person was driving.
- Passenger Front Seat
- Middle front seat passenger
- Back seat behind the driver
- Back seat on the passenger side
- Middle of the back seat
- Passenger other
Who owned the vehicle the injured person was in at the time of the collision?*
- The injured person owned the car that was involved in the crash.
- A relative of the injured person owned the car that was involved in the crash.
- A friend owned the car.
- The Injured person was in a commercial vehicle, such as a work vehicle.
- Injured person was in a cab, Uber, Lyft, Buss or some public transportation.
Name of the person who owned the car the injured person was in at the time of the collision
First Last
The name of the company that owned the vehicle that the injured person was in is:*
Do you have the address of the owner of the vehicle the injured person was in at the time of the crash?
Address of the vehicle owner that the Injured person was riding in at the time of the collision*
Street Address City State ZIP Code
Which vehicle was the AT FAULT driver, driving?*
If you were a passenger, was the driver of your car at fault?
Were you wearing your seat belt at the time of the collision?*
- Yes, I was wearing my seat belt.
- No, I was not wearing a seat belt at the time of the collision.
How many vehicles were involved in the collision?*
- 1, it was just a single car collision, no other vehicles were involved.
- 2 vehicles were involved in the crash.
- 3 vehicles were involved in the crash.
- 4 or more vehicles were involved in the crash.
How experienced were you at riding a motorcycle?*
- I was a beginner motorcycle rider
- I was a fair rider who rode only once in a while
- I was a very experienced rider that rode often
Motorcycle Crash
How experienced were you at riding a bicycle?*
- I was a beginner bicycle rider.
- I was a fair rider who rode only once in a while
- I was a very experienced rider that rode often
Motorcycle Crash
At the time of the crash did you own a bike helmet?*
- Yes, I owned a bike helmet at the time of my crash.
- No, I did not own a bike helmet at the time of my crash.
Bicycle Crash
At the time of your collision were you wearing a Bike Helmet*
- Yes, at the time of my collision I was wearing my helmet.
- No, I was not wearing my helmet at the time of the crash.
Bicycle Crash
What kind of Bike Helmet were you wearing when the crash happened?*

Bicycle Crash
What make and model bike was being ridden at the time of the collision?*

Bicycle Crash
Where is the bike now?*

Bicycle Crash Please stop riding the bike, save it as evidence we can use at trial if needed.
Mark the items that were on the bike*
- headlight
- tail light
- reflectors on the front of the bike
- reflectors on the back of the bike
- reflectors on the spokes of the wheels
- front hand brake
- rear brake that works when you pedal backwards
- rear hand brake
- Reflective riding vest
Bicycle Crash
Did you have a Motorcycle Endorsement on your Driver's License?*
Did our injured client have a Motorcycle Endorsement on their Driver's License?*
Motorcycle Crash
Did you take and pass a Motorcycle Safety Class?*
- Yes, I took and passed a Motorcycle Safety Class.
- No, I either did not take a class, or did not pass a Motorcycle Safety Class.
Motorcycle Crash
Did our injured client take and pass a Motorcycle Safety Class*
Motorcycle Crash
When and where was the Motorcycle Safety Class?

Motorcycle Crash
Check each type of riding gear that was worn*
- Helmet - full face
- Helmet - 3/4 open face
- Helmet - full face modular
- Helmet - Skull cap
- Clear visor attached to my helmet
- Sun glasses
- Goggles
- Riding Gloves
- Motorcycle boots
- Long sleeved shirt
- Riding jacket
- Long pants
- Long pant jeans
- Reflective clothing
- bright colored vest
- Rain Jacket
- Rain Pants
- None of the above were worn
Motorcycle Crash
Describe any other riding gear or clothing you wore
Motorcycle Crash Anything else that may be of interest, such as wearing a back pack, scarf around your face or neck.
Can you arrange for us to photograph the damaged items?*
- Yes, I can help arrange a time for you to photograph the damaged items.
- No, you don't need to, I have already taken photos
Pedestrian v MVA accident:
Mark any and all features on your bike
- Windscreen
- Anti Lock Brakes
- Additional LED lights or similar lighting effects
Motorcycle Crash
Did you know a collision was going to happen before it did?*
- Yes, I knew that a crash was going to happen before it did.
- No, I had no idea a crash was about to happen before it did.
What did you see that let you know a collision was about to happen?*
Describe what you saw before the impact.
What evasive action of anything did you take to avoid the crash?*
Did an airbag deploy in your car?*
- No, there was no air bag deployment in my car.
- Yes, my airbag where I was sitting did go off.
- Yes, an airbag did go off but it was not my airbag.
Was the car that you were in working well at the time of the crash?*
- Yes, the car I was in was working well, all the lights worked, brakes, steering, etc.
- No, there were some problems with the car I was in.
- I don't know if the car I was in was working properly or not.
Did your car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Describe the mechanical problems with your car*
Describe what was wrong with your vehicle
Weather Conditions were?
- Clear skies
- Overcast
- Raining
- Foggy or smokey
- Wet roads
- Flooded roads
Road Conditions*
- No Traffic
- Clear roads
- Light Traffic
- Medium Traffic
- Heavy Traffic
- Stop and Go bumper to bumper traffic
- Construction in the area
- Other accidents happened and people were rubber necking
Was alcohol or drug use any part of this accident?*
- No, alcohol and drugs were not a part of this accident.
- Yes, the other parties used drugs or alcohol.
- Yes, I had consumed alcohol or drugs.
- I don't know if drugs or alcohol were involved in this accident.
Was anyone intoxicated during the accident?
Did you consume and alcohol or drugs in the 12 hours before the fall?*
- No, I had not consumed any alcohol or drugs 12 hours before the fall.
- Yes, I had consumed alcohol or drugs
Was anyone intoxicated during the accident?
What role did alcohol or drugs have in this accident*

Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Were you partially at fault for this accident?*
- No, I was not at fault in any way
- Yes, I may be partially at fault
What did you do wrong that may have contributed to the accident?*
Where was the first point of impact on your vehicle
- Hit squarely on the rear
- Hit the back bumper drivers side
- Hit the back bumper passenger side
- Front of my car dead center
- Front corner of my car drivers side
- Front corner of my car passenger side
- Drivers side of my car
- Passenger side of my car
Right before the impact was your vehicle:*
- At a complete stop.
- Slowing down to stop
- Braking hard to stop
- Traveling at the same speed as the flow of traffic.
How many seconds were you at a full stop before being hit from behind?*
- 1 second stop before being hit from behind.
- 2 to 5 seconds we were stopped before behing hit.
- 5 to 10 seconds we were stopped before being hit from behind.
- 10 seconds or more before being hit from behind.
Where was the first point of impact on the at fault vehicle
- Dead front and center of the other car
- Front drivers corner
- Front passenger corner
- Rear of the other car
- Drivers side of the car
- Passenger side of the car
- There was no contact by the at fault vehicle
Where was the first point of impact from the truck*
- Dead front and center of the truck
- Front drivers corner or the truck
- Front passenger corne of the truck
- Rear of the truck
- Drivers side of the truck to the cab of the truck
- Passenger side of the truck to the cab of the truck
- There was no contact by the truck
- The trailer being pulled by the truck on the drivers side
- The trailer being pulled by the truck on the passenger side
- The back wheels of the truck
Describe what happened that caused the accident.*
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the At Fault Driver, Person or Company do that lead to the collision?*
What specifically did the at fault driver do? Why are they the one at fault for this collision?
Where was the first point of impact to you or your bike?*
- My front wheel
- My back wheel
- The right side of my bike
- The left side of my bike
- My bike did not touch the other vehicle, but I lost control
Motorcycle Crash Bicycle Crash
After the impact between the vehicles, how far apart were they before anyone moved them from the crash.*
Did you hear the at fault person say anything about the crash?*
The at fault person said the following*
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.
Describe the mechanisim or how you fell, for example, my left foot went into something slipery and my left foot slipped forward and I fell down on my right knee, etc.*
What foot went first, where did it go, what happened next in the fall. Please give as much detail as you can about the fall
Witness Identification who may be a witness?
How many people besides yourself were in your vehicle?*
The name of the First other person in your vehicle*
First Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the First Other person in Your Vehicle?*
- Yes, I have the address of the First Other Person in my car with me.
- No, I do not have the address of the First Other Person in the car with me.
What is the Address of the First Other Person in your Vehicle
Street Address City State ZIP Code
I believe the First Other Person in my vehicle*
- was injured also and wants MattLaw to be their lawyer
- was injured and will get their own laywer
- was not injured and is just an eye witness who will help the case
- was at fault in some way for the accident and I want to make a claim against them
- is too young to know anything about what happened
The name of the Second other person in your vehicle*
First Last
Do you have the address of the Second Other person in Your Vehicle?*
- Yes, I have the address of the Second Other Person in my vehicle with me.
- No, I do not have the address of the Second Other Prson in my vehicle with me.
What is the Address of the Second Other Person in your Vehicle
Street Address City State ZIP Code
I believe the Second Other Person in my vehicle*
- was injured also and wants MattLaw to be their lawyer
- was injured and will get their own laywer
- was not injured and is just an eye witness who will help the case
- was at fault in some way for the accident and I want to make a claim against them
- is too young to know anything about what happened
The name of the Third other person in your vehicle*
First Last
Do you have the address of the Third Other person in Your Vehicle?*
- Yes, I have the address of the Third Other Person in my vehicle.
- No, I do not have the address of the Third Other Preson in my vehicle.
What is the Address of the Third Other Person in your Vehicle
Street Address City State ZIP Code
I believe the Third Other Person in my vehicle*
- was injured also and wants MattLaw to be their lawyer
- was injured and will get their own laywer
- was not injured and is just an eye witness who will help the case
- was at fault in some way for the accident and I want to make a claim against them
- is too young to know anything about what happened
The name of the Fourth other person in your vehicle*
First Last
Do you have the address of the Fourth Other person in Your Vehicle?*
- Yes, I do know the address of the Fourth Other Person in my Vehicle.
- No, I do not know the address of the Fourth Other Person in my Vehicle.
What is the Address of the Fourth Other Person in your Vehicle
Street Address City State ZIP Code
I believe the Fourth Other Person in my vehicle*
- was injured also and wants MattLaw to be their lawyer
- was injured and will get their own laywer
- was not injured and is just an eye witness who will help the case
- was at fault in some way for the accident and I want to make a claim against them
- is too young to know anything about what happened
How many Eye Witnesses are you aware of?*
Name of Eye Witness 1*
First Last
What is the name of the first eye witness who you have not told us about already?
Name of Eye Witness 2*
First Last
What is the name of the first eye witness who you have not told us about already?
How do we get in touch with any eye witness? Phone number, address, anything to help us find and talk with them.*
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
Which of the following do you still have?*
- Some of the wrong medicine they gave to me
- The bottle or box the medicine came in
- The receipt of my purchase of the wrong medicine
- Nothing
Help us save, and preserve this evidence. We want to photograph it, measure how much was left, and help prove how much you took.
Why do you have Nothing? What happened, please explain*
Pharmacy Negligence Did they ask for it back and you complied? Did you throw it away, if so, when and why?
How many vehicles were involved in the crash?*
Color and make and year of the at fault car*
How many people were in the at Fault vehicle?*
Did the police come to the scene of the crash?*
- No law enforcement came to the scene
- Yes they came and;
- They did a Drivers Exchange only
- They did a Crash Report
- They arrested the at fault driver
Law Enforcement that came to the crash were*
- City Police Department
- County Sherrif
- Florida Highway Patrol
- I'm not sure
Which City Police Department?*
What is the Police Report Case Number?*
Did anyone get a Traffic Ticket or was there any arrests?*
- No, no one got a ticket.
- I don't know if anyone got a ticket.
- Yes, I did get a ticket.
- Yes, another driver did get a ticket.
- Yes, I got a ticket and so did another driver.
- Yes, the other driver was arrested for DUI.
- Yes, the other driver was arrested for something else.
Do you know what the other driver was ticked for?*
What was the other drivers ticket for?*

Enter what their ticket was for. For example, following too closely
What were you ticketed for?*

If you got a traffic citation, what was it for?
Do you want to hire a separate lawyer to fight your ticket?*
- I will take care of the traffic ticket myself.
- I would like MattLaw to help me find a lawyer to fight the ticket
Status of any Traffic Court or Criminal Court Dates*
- I am unaware of any traffic court dates
- Yes, there is a Court date scheduled
- No, the traffic court case is over
Were there any Skid Marks our gouges left in the road?*
- None. There were no skid marks left on the ground.
- Yes. There were skid marks left on the ground.
Describe the Skid Marks or Gouges.*

Which vehicles left skid marks, which vehicles left gouges in the road, how long were they, where were they located?
EVIDENCE Section Break Marker to help me find location in form
Photographs Check all that you have or have access to*
- I have no Photos
- Property Damage Photos
- Scene of the crash Photos
- I have Photos of the skid marks
- I have Photos of the traffic signals and signs where the crash happened
- Cuts, scars, bruises or medical treatment Photos
Evidence
Check off any clothing items that were damaged in any way by this collision*
- Hat
- Shirt
- Jacket
- Belt
- Pants
- Shoes
- eye glasses
- sun glasses
- purse
- brief case
- umbrella
- cell phone
- computer
- other things not on this list
- Nothing was damaged
Pedestrian v MVA accident: We would like to see and photograph any damaged clothing, such as shoes, or pants, jackets. Even personal property like a purse, brief case or other items
Do you still have the damaged items?*
- Yes, I still have the damged items from the collision.
- No, I do not have the damaged items from the collision.
Pedestrian v MVA accident:
Do you have any photographs of where you fell?*
- Yes. I have photos of where I fell.
- No. I do not have any photos of where I fell.
Are there any photographs of the injuries, or damages?*
- Yes. There are photographs of injuries or damages.
- No. There are no photographs of injuries or damages.
Do you want us to hire a photographer to take photos of anything?*
- No, there is nothing to photograph at this time
- Yes, the vehicle has not been fixed yet and it is worth photographing
- No, don't hire anyone, I will either take the pictures myself or have a friend do it
- Yes, I think if we took photos of the scene it would help prove our case
- Yes, please take photos of my car and the scene
Where is the Car to be photographed?*
Who else may have any photographs or evidence to help prove your case?
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
Where is the Motorcycle to be photographed?*
Where is the Motorcycle to be photographed?*
Where is the Bicycle to be photographed?*
Where is the Bicycle to be photographed?*
Can I take a picture of you now just for our files?*
- Yes. Please take a photo of me for your files.
- No. Please do not take a photograph of me.
What other evidence might exist that we should try to obtain to help prove your case? Who has it, what is it, how do we get it?
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
Who visited the patient, what is their relationship, and frequency of visitations?*
NURSING HOME ABUSE: Who can we talk to about the health care and abuse to the victim? How often would they visit? What did they notice, and how can we get into contact with them?
Who visited the patient, what is their relationship, and frequency of visitations?*
NURSING HOME ABUSE: Who can we talk to about the health care and abuse to the victim? How often would they visit? What did they notice, and how can we get into contact with them?
What medical treatment did you have after the Pharmacy Mistake*
Tell us about any medical treatments, hospitalizations, surgeries therapies that you have had after the pharmacy mistake.
Who are your treating doctors now?*
Med Mal Alive Please provide the names, addresses and phone numbers of your treating doctors that you are seeing now on a frequent basis.
Have any of your doctors said that you should see a lawyer?*
- Yes. I was told by my doctors to hire a lawyer.
- No. No doctor has told me to hire a lawyer.
Med Mal Alive
What is the name of the doctor who told you to see a laywer and what and when did they tell you this?*
Med Mal Alive
What have any of your doctors told you about your health problems you have now?*
Med Mal Alive What have the doctors explained about your future recovery and or treatments and prognosis. Are you getting better, staying the same, or worse?
What happened after you got the medication? What symptoms or problems started to affect you?*
Pharmacy Negligence Describe the reaction you experienced after taking the wrong medication as well as how it has changed your life, what permanent losses have you experienced if any?
What parts of your body were injured by the medication error?*
Please describe each and every problem or injury you have experienced by the medication error. What would you tell a jury if they asked, "How were you injured by the mistake?"
Did Fire Rescue Come to the Scene*
- No. No Fire Rescue came to the scene.
- Yes, and Fire Rescue checked me out and left me at the scene
- Yes, and Fire Rescue took me to the hospital
- Yes, and Fire Rescue took someone else to the hospital
Was Fire Rescue ever involved in helping you from the pharmacy mistake?*
- No. No Fire Rescue was never involved in my care.
- Yes. I used Fire Rescue at least one time due to my injuries.
Was Fire Rescue ever involved in helping you from the Medical Malpractice?*
- No. No Fire Rescue was ever involved.
- Yes. Fire Rescue was involved in my care.
Was Fire Rescue ever involved in helping you from the Nursing Home Neglect?*
- No. Fire Rescue was never involved in care.
- Yes. Fire Rescue was involved in the care.
Which Fire Rescue Department came to the scene of the crash?*

Tell us the name of the Fire Rescue department so we can order the records.
Did you go to a Hospital as a result of this incident?*
- No. I did not go to the hospital.
- Yes. I did go to the hospital because of this.
When did you go to the hospital?*
- That same day as the accident I went to the hospital.
- The next day after the accident I went to the hospital.
- A few days later I went to the hospital.
What is the name and location of the Hospital you went to?*
How did you get to the hospital?*
- Ambulance
- Helicopter
- Fire Rescue
- I drove myself
- A friend drove me to the hospital
Who drove you to the hospital?*
First Last
Were you admitted to the hospital over night*
- No, they checked me out and sent me home that same day/night
- Yes I was admitted into a room
What was the date that you went to the hospital?*
Month
Day
Year
Were you examined by any medical personnel*
- Yes. Yes, I was examined by medical professionals.
- No. No, I was not examined by medical professionals.
NEGLIGENT SECURITY Did any medical person use a Rape Kit to collect DNA samples from you after the attack?
What Date were you discharged from the hospital*
Month
Day
Year

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.
Check the boxes for all injuries you received from this crash*
- No Injuries
- Head Injuries, cuts, scrapes, bumps
- Loss of consciousness for even a second
- Head aches
- Jaw pain or clicking
- Feeling dizzy
- Blurred vission
- Short term memory loss
- Neck pain
- Shoulder pain
- Arm pain
- Numbness or tingling going down my arm or arms
- Hand or wrist pain
- Numbness or tingling in my hands or fingers
- Shooting pain in shoulders, arms, elbows, writs, hands or fingers
- Mid back pain
- Seat belt or shoulder belt bruising or scrapes
- Air bag burns to my face, arms or hands
- Low back pain
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- ankle pain
- Foot pain
- Bruises
- Cuts that will leave a scar
- Road Rash
Check the boxes for all injuries you received from this crash*
- No Injuries
- Head Injuries, cuts, scrapes, bumps
- Broken Bones
- Loss of consciousness for even a second
- Head aches
- Jaw pain or clicking
- Feeling dizzy
- Blurred vission
- Short term memory loss
- Neck pain
- Shoulder pain
- Arm pain
- Numbness or tingling going down my arm or arms
- Hand or wrist pain
- Numbness or tingling in my hands or fingers
- Shooting pain in shoulders, arms, elbows, writs, hands or fingers
- Mid back pain
- Low back pain
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- ankle pain
- Foot pain
- Bruises
- Cuts that will leave a scar
- Road Rash
Motorcycle, Bicycle Crash or Pedestrian Accidents Only
Check the boxes for all injuries caused by the nursing home neglect.*
- Bed sores, decubitus ulcers, pressure sores
- Unexplained bruises
- Unexplained broken bones
- Deyhidration
- Malnurishment
- Over medication
- Under medication
- Emotional upset, aggitated or withdrawn and non communicative
- Falls
- Infections
- Rapid weight gain or weight loss
- Fear of speaking in front of staff members
- Unexplained welts or bruises, or healing bruises
- Unsanitary conditions
- Soiled bedding
- Soiled clothing
- Loss of personal property
- Victim of assault or battery
- Rape or secual assault
- Physical restraints being used
- Medical restraints being used
- Episodes of wandering
- Long delays in care or treatment
Injuries or illness that occurred*
Workers Compensation no death
Describe and list the part of the body affected by the accident*
Workers Compensation
Describe any and all injuries you relate to this car crash*
What other injuries or physical or psychological problems are you having that you relate to this crash.
What doctors or health care people have you seen since the crash?*
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.
Have you been prescribed any medications?*
- Yes. Yes, the doctors prescribed medications for this.
- No. No, I have not been prescribed any medications.
Injuries
What medications have you been prescribed because of this incident*
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.
Have you been prescribed medications but have not yet filled the prescription? Why?*
- Yes, I have been given prescriptions and I filled them
- No, I have not been prescribed any medications
- I don't like taking medications
- I can't afford to get the prescription filled
- I have not had time to get them yet
Did you know that Pre-Existing Injuries or conditions can make your case worth more money, not less?*
- Yes, because that makes me easier to hurt and harder to fix
- No, I did not know that, but I am glad you told me
What medications were you taking on a regular basis before this crash?*
What medications were you taking on a regular basis before this Pharmacy Mistake?*
What doctors or health care people have you seen since the Pharmacy Mistake?*
Please tell us all the doctors, chiropractors, X-ray, MRI facilities that you have been to after the Pharmacy mistake. Name, city, location, so that we can order all of your medical records.
Check the boxes for Prior Injuries you have sought treatment for BEFORE this incident*
- None, I have never been treated for any prior injury or illness
- Head Injuries, cuts, scrapes, bumps
- Loss of consciousness for even a second
- Head aches
- Jaw pain or clicking
- Feeling dizzy
- Blurred vission
- Short term memory loss
- Neck pain
- Shoulder pain
- Arm pain
- Numbness or tingling going down my arm or arms
- Hand or wrist pain
- Numbness or tingling in my hands or fingers
- Shooting pain in shoulders, arms, elbows, writs, hands or fingers
- Mid back pain
- Low back pain
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- ankle pain
- Foot pain
Check the boxes for Prior health conditions BEFORE going into a nursing facility.*
- None, I have never been treated for any prior injury or illness
- High blood pressure
- Diabetes
- Cancer
- Demensia
- Alzheimers
- Hepitities
- Short term memory loss
- COPD
- Difficulty walking
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- Foot pain
- Skin ulcers
- Compromised immune system
Describe your prior treatment, Who, What When and Where*
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.
List all hospitals you have been in over the past 10 years*
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.
Prior Chiropractic Care*
- Yes. I have been to a chiropractor before this incident.
- No. I have never been to or ever seen a chiropractor.
Have you ever seen a chiropractor, even for one visit before this incident?
What Chiropractors have you seen and what address can we request your records?*
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 had prior psychiatric or psychological care or counseling?*
- Yes. I have previously seen or been to a psychiatrist or psychologist before this.
- No. I have never been to a psychiatrist or psychologist ever in my life before this incident.
Have you ever seen a psychiatrist, psychologist, or been baker acted before this incident?
What psychiatrists or psychologists have you seen and what address can we request your records?*
We need the name, address and approximate date that you saw any mental health professionals before this accident.
Have you ever had a Workers Compensation Claim?*
- Yes. I have had a workers comp claim in the past.
- No. I have never been hurt on the job, never had a workers compensation claim.
Tell us about your Workers Compensation Claim(s)*
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Has any doctor taken you off of work because of your injuries in this incident?*
- No. No doctor has taken me off of work for this accident.
- Yes. My doctors have given me a work note to take time off or work less hard.
Have you been given a work disability slip from anyone because of your injuries from this car crash?
How much work have you missed, or will you miss?*

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.
Which doctor specifically wrote a work restriction for you?*

Please give us the name and location of the doctor that has taken you off of work. We need to order your records
What is your best estimate of how much money you will lose (going forward only) as a result of your work restrictions.*
What is your estimated Lost wages (in the past only) so far?*

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
What Insurance Coverages do you have on your own Personal Policy?*
- None. I had no auto insurance myself.
- PIP No Fault - Required
- Property Damage to other vehicles - Required
- Medical Payments - Optional
- Bodily Injury - Optional
- Uninsured / Underinsured Motorist coverage - Optional
- Collision for the car involved in this crash - Optional
- Umbrella Liability Policy - Optional
- Umbrella UM Coverage - Optional
What is the name of your insurance company?*
What is your insurance Policy Number?*
Are all of your insurance policies "Florida" Policies?*
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.
Which State is your Insurance Policy written for?*
If you don't have a Florida insurance policy, which state is the policy from?
Which of your out of State Insurance policies are Not Florida policies?*
- PIP No Fault
- Med Pay
- Uninsured Motorist
- Umbrella
What are your Med Pay Policy Limits?

If you know your limits please indicate this, if you don't know, put Unknown
What are your UM Limits?

What are the limits on your UM policy?
Do you have STACKED UM Coverages?*
- Yes - I have stacked UM
- No - I know for sure I do Not have Stacked UM
- I am unsure if I have Stacked UM or not.
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.
How many vehicles do you own, Cars, trucks, motorcycles*
Please enter a number from 1 to 9.
What is the total number of motor vehicles that you own that may provide UM coverage to you?
What other Insurance Companies do you have any MVA Policies with?*
- None - All my insurance is with one company
- Yes, I have Motor Vehicle Insurance with more than one company
- I am not sure, but my insurance agent will know for sure
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.
My Umbrella Insurance Company is:*
My Umbrella Policy Number is:*

Provide your Umbrella Policy Number if known, if you don't know, enter Unknown
Does your Umbreall Policy offer UM Coverage?*
- Yes. My Umbrella Policy has Uninsured/ Underinsured "UM" coverage.
- No. I do not have UM coverage on my Umbrella.
- I don't know if my Umbrealla policy gives me Uninsured/ Underinsured coverage.
Is your UM Umbrella STACKED?*
- Yes. My Umbrella UM policy is a Stacked Policy which gives me multiples of coverage.
- No. I did not purchase Stacking UM coverage on my Umbrella.
- I don't know if my Umbrella policy has Stacked Coverage.
If you have Stacked UM Umbrella Insurance please let us know.
What other Insurance Companies do you have coverage with?*
Who is your Insurance Agent so we can ask about your Insurance Policies*

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.
End of UM and Other Insurance coverage
PIP Questions to find out which PIP policy you can get
At the time of the crash did you own any 4 wheeled vehicles?
- Yes. At the time of this crash I owned a car. Select this even if the car was not involved in this crash.
- No. At the time of this crash I did not own any car.
Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage.
At the time of the crash did you own any car or any 4 wheel vehicles?
- Yes. At the time of this crash I owned a car. Select this even if the car was not involved in this crash.
- No. At the time of this crash I did not own any car.
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.
Was the Car you owned at the time of the crash Insured?*
- Yes. I had insurance on the car I owned at the time of the crash.
- No. I did not have any insurance on the car that I owned at the time of the crash.
Is your vehicle being operated on the roads of Florida?*
- Yes. The vehicle that I owned was normally being driven in Florida.
- No. My vehicle was not used or in Florida, it was an out of state vehicle.
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.
At the time of the crash did you live with any relative?*
- Yes, I lived with a resident relative
- No, I did not live with any resident relative
Did you live with any relatives? This includes parents, spouse, child, brother, sister, grandparent. If they did, then they get Pro-rata amount the policies in the household.
How many relatives did you reside with that had their own car insurance policies?*
What is the name of the First relative that you lived with at the time of the crash that has their own car insurance policy?*
First Last
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.
What is the name of the Second relative that you lived with at the time of the crash that has their own car insurance policy?*
First Last
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.
What is the name of the Third relative that you lived with at the time of the crash that has their own car insurance policy?*
First Last
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.
Name of your First Resident Relative's Insurance Company*
Name of your Second Resident Relative's Insurance Company*
Name of your Third Resident Relative's Insurance Company*
You have No PIP insurance to pay your medical bills or lost wages
Because you owned a car and did not have insurance on that car, only your health insurance or disability insurance will pay your medical bills and lost income, unless we recover them from the at fault parties.
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.
Were you the owner of the vehicle you were in at the time of the crash?*
- Yes. I owned the vehicle that I was in at the time of the crash.
- No. I was not the owner of the vehicle I was in at the time of the crash.
What is your insurance Company Adjuster's Name?
First Last
What is your insurance companie's Phone number?
What is your Policy Number?*
What is your Claim Number?*

Enter the claim number or if you don't have one enter Unknown.
Does the owner of the vehicle you were in have PIP?*
- Yes. The owner of the vehicle I was in was insured and had PIP.
- No. The owner of the car I was in did not have any insurance.
If yes, they get PIP from the owners policy. If no, they are out of luck, no PIP
Who was the titled owner of the car that you were in at the time of the crash?*
- I leased the vehicle but did not own it
- The vehicle was owned by a family member
- I did not have any ownership in the vehicle I was in at the time of the crash because it was my friends vehicle
- It was my employer's vehicle
- It was a rental car rented by me
- It was a rental car but rented by someone other than me
Who owned the vehicle that you were in when the collision occurred?*
First Last
Which Rental Car Company owned the vehicle you were in*

We need the name of the rental company so that we can find out what insurance was taken out that may protect you.
Who rented the car that you were in at the time of the crash?*
First Last
Were you covered under any Car Insurance at the time of the crash?*
- Yes. I was covered under a car insurance policy at the time of the collision.
- No. I was uninsured at the time of the collision.
At the time of this crash, did you have any car or motorcycle insurance for any of your vehicles? Or, if you rented the vehicle, did you have any insurance coverage through the rental car company, or your credit card?
Were you the "Named" Insured under that car insurance policy?*
Was the insurance in your name?
Who is the "Named" Insured under the policy?*
First Last
End of PIP beginning of At Fault Insurance
This is where we start recording that At Fault Insurance Company information.
Did you report the accident?*
- Yes. After the fall I notified the manager or employees.
- No. After the fall, I did not tell anyone there about it.
Slip and Fall Did you notify the owner or management or any employee about the incident?
Who did you report the accident to?*

Slip and Fall Name of the person you told about the fall, or the position of the person who you talked to, like a manager, the owner, a lower level employee
Was an accident report made?*
- Yes. I believe an accident report was made.
- No. I don't think any report was made.
- I don't know if an accident report was made or not.
Slip and Fall
Did you get a copy of the accident report*
- Yes. They game me a copy of the accident report.
- No. They did not give me a copy of the accident report.
Slip and Fall Did they give you a copy of the accident or incident report?
Did you sign any report or other document*
- Yes. I signed some papers for them.
- No. I did not sign anything.
Slip and Fall Did the manager or store or anyone have you sign anything such as an accident report or medical release authorization?
Did you get a copy of what you signed?*
Slip and Fall
What did the person you reported the accident to say about the incident?*
Slip and Fall Please tell me everything that you and anyone at the location discussed about the incident? Any admissions made by them, such as we knew about the problem but were too busy to get to it. . .
Do you know if the at fault party has any insurance?*
- Yes, I know that at fault party has insurance.
- No. I a certain that the at fault party or person does not have any insurance to pay for my damages.
- I don't know if the at fault person or company has any insurance to pay my damages.
Slip and Fall
What is the name of the insurance company?*

Slip and Fall Tell us the name of the insurance company. If you don't know, just put "unknown"
What is the Claim Number of the claim, if you know

Slip and Fall
What is the Adjusters Name?

Slip and Fall
Do you have a phone number for the insurance company or claims adjuster?*
Slip and Fall
Do you believe there were any surveillance cameras around you*
- Yes. I believe that this incident was videotaped by surveillance cameras.
- No. I do not believe that there were any surveillance cameras around when I got hurt.
Slip and Fall Do you think they have any surveillance video of you in and around the area?
What other information can you give us about this fall?
Slip and Fall What else would help us contact that at fault party, contact any witnesses, or help document whose fault this was?
Which Insurance Companies have contacted you so far?*
- None. No insurance company has contacted me.
- My Insurance Company has contacted me.
- The at fault driver's Insurance Company has contacted me.
- An investigator or some other insurance company has contacted me.
What is the Name of the Pharmacist that Mis Filled your prescription?
Prefix First Middle Last Suffix
Pharmacy Negligence
Type of Medication you were supposed to get*

Pharmacy Negligence Name of medication, quantity of medication, like so many milligrams, and frequency of the medication, how often were you to take it?
What medication did they give you by mistake?*

Pharmacy Negligence
What conversations did you have with the pharmacy afterwards? What did they say to you?*
Pharmacy Negligence What statements or admissions have they made, such as "it is our fault," "we made a mistake," "we gave you the wrong medicine," "we gave you the wrong person's medication."
Were you taking any other medications at the time of the mistake?*
- Yes. I was taking other medications at the time of the pharmacy mistake.
- No. I was not taking any other medications around the time of the pharmacy mistake.
Pharmacy Negligence
What were the other medications you were taking, and where did you get those prescriptions filled?*
Pharmacy Negligence ***Note, this may be a redundant question***
Name of the At Fault Driver*
First Middle Last
Address of the At Fault Driver
Street Address City State ZIP Code
Date of Birth of the At Fault Driver
Month
Day
Year
At Fault Drivers Licnese Number
Who is the At Fault Driver's Insurance Company*

Name of the At Fault Insurance Company
What is the At Fault Driver's Insurance Company Claim Number*

When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Name of the At Fault Insurance Company Adjuster*
First Last
Phone number for the At Fault Insurance Company or adjuster
The owner of the vheicle that was at fault is:*
- The same person as the driver
- I know who owned the vehicle
- I don't know who the owner was
Name of the Owner of the At Fault Vehicle
First Middle Last
Address of Owner of the At Fault Vehicle
Street Address City State ZIP Code
Owner's Insurance Company Name

Name of the Insurance Company for the Owner of the vehicle that was at fault.
Owner's Insurance Company Claim Number

When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Owner of the Vehicle's Fault Insurance Company Adjuster
First Last
Phone number for the vehicle Owner's Insurance Company or adjuster
Do you believe the at fault driver was working or running an errand for someone else?*
- No. I don't think that at fault driver was working or running any errand at the time of the crash.
- Yes I think the bad driver was working or running an errand at the time of the collision.
What is the name of the drivers Employer?*

Who was the driver working for when he caused the crash? We will sue his employer also.
What makes you think they were working at the time of the accident?*
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
What are your medical bills so far to date?*
How much money has it cost to treat you for the injuries that you sustained as a result of the doctors mistake? Not just your normal medical bills, but the ones that are caused by negligence?
What are the financial damages you will have or will suffer because of the malpractice?*
Med Mal Alive In most cases to bring a medical malpractice claim with our office, our client needs to have over $250,000.00 in damages excluding things like pain and suffering. These damages are based upon past medical bills that stem from the malpractice, and/or future medical bills for conditions caused by the malpractice, and/or lost wages in the past, or loss of the ability to earn money in the future. Please explain what the financial costs will be as a result of the negligence.
Health Insurance Yes or No*
- No, I have no health insurance of any kind.
- Yes, I have health insurance.
Do you have any type of Health Insurance?
Name of your Health Insurance Company*
What is your Health Insurance Policy Number*
Has Health Insurance paid any of your bills?*
- Yes. My Health Insurance has paid some of my medical bills.
- No. My Health Insurance has paid none of my medical bills.
- I don't know if my Heath Insurance has paid any medical bills.
Effective Date of your Health Insurance
Month
Day
Year

This date is on your health insurance card and it tell us when your coverage first began.
Heatlh Insurance Information, What is the contact information for your Health Insurance*
Medicare Yes or No*
- No, I do not have Medicare
- Yes, I have Medicare
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 parts of Medicare do you have, check all that apply*
- I have Medicare part A
- I have Medicare part B
- I have Medicare part C
- I have Medicare part D
Name of your Medicare Insurance Company for Part A*

What is the name of Part A
What is your Medicare Part A Policy Number*

We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part A paid any of the bills related to this incident?*
- Yes, Medicare Part A has paid some bills related to this incident
- No, Medicare Part A has paid nothing related to this incident
- I don't know if Medicare Part A has paid anything
We need to know if medicare part A has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part A Insurance
Month
Day
Year

This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part B*

What is the name of Part B Medicare Insurance Company
What is your Medicare Part B Policy Number*

We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part B paid any of the bills related to this incident?*
- Yes, Medicare Part B has paid some bills related to this incident
- No, Medicare Part B has paid nothing related to this incident
- I don't know if Medicare Part B has paid anything
We need to know if medicare part B has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part B Insurance
Month
Day
Year

This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part C*

What is the name of Part C Medicare Insurance Company
Effective Date of your Medicare Part C Insurance
Month
Day
Year

This date is on your Medicare insurance card and it tell us when your coverage first began.
Has Medicare Part C paid any of the bills related to this incident?*
- Yes, Medicare Part C has paid some bills related to this incident
- No, Medicare Part C has paid nothing related to this incident
- I don't know if Medicare Part C has paid anything
We need to know if medicare part C has paid any money to help with your care as a result of this incident?
What is your Medicare Part D Policy Number*

We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Effective Date of your Medicare Part D Insurance
Month
Day
Year

This date is on your Medicare insurance card and it tell us when your coverage first began.
Has Medicare Part D paid any of the bills related to this incident?*
- Yes, Medicare Part D has paid some bills related to this incident
- No, Medicare Part D has paid nothing related to this incident
- I don't know if Medicare Part D has paid anything
We need to know if medicare part D has paid any money to help with your care as a result of this incident?
Medicare Information, What is the contact information for your Medicare*
Do you (injured person) have Medicaid? Yes or No*
- No, Medicaid
- Yes, have Medicaid
Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
Name of your Medicaid Insurance Company*
What is your Medicaid Policy Number*

We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
Effective Date of your Medicaid Insurance*
Month
Day
Year

This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Medicaid paid any of the bills related to this incident?*
- Yes, Medicare has paid some bills related to this incident
- No, Medicare has paid nothing related to this incident
- I don't know if Medicare has paid anything
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.
Do you (injured person) have Wellcare? Yes or No*
- No, I don't have Wellcare.
- Yes, have Wellcare
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.
Name of your Wellcare Insurance Company*

It might be called just Wellcare, and it may be managed by another company. We need the company name.
What is your Wellcare Policy Number*
Effective Date of your Wellcare*
Month
Day
Year

This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Wellcare paid any of the bills related to this incident?*
- Yes, Wellcare has paid some bills related to this incident
- No, Wellcare has paid nothing related to this incident
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.
Medicaid contact information*
What is their address or contact information for Medicaid?
Do you have any sort of Disability Insurance*
- No, I have no Disability Insurance
- Yes I have Disability Insurance
If you have any disability insurance that may pay you benefits please let us know about them.
Name of your Disability Insurance Company*
Has your Disability Insurance made any payments to you*
- Yes my Disability Insurance has paid me some lost wages
- No, my disability insurance company has not paid me anything for this accident
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.
Notes regarding Insurance-Medicare-Medicade or any other Collateral Source
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
Do you know if the bad nursing home is Medicaid or Medicare Certified?*
- Yes. The nursing home was Medicaid and or Medicare Certified.
- No. The nursing home was NOT Medicaid or Medicare Certified.
- I don't know if the nursing home was Medicaid or Medicare Certified.
NURSING HOME ABUSE: If the Defendant facility is Medicaid or Medicare Certified, then they have additional record keeping that they must do which will help us prove the case.
End of Health Insurance
Beginning of Property Damage MVA
Is there a claim for Property Damage to your car?*
- No because there was no damage to fix
- No because it was not my car that was damaged
- No because the Property Damage claim has been resolved
- Yes, the Property Damage Claim is not resolved yet
Is there a claim for Property Damage to your bike*
- No because there was no damage to fix
- No because the Property Damage claim has been resolved
- Yes, the Property Damage Claim is not resolved yet
What kind of vehicle do you have*

What kind of car was damaged in this crash?
What kind of bike do you have*

What kind of bike was damaged in this crash?
What Year is your vehicle*
What Year is your bike*
What color is your vehicle*

What color is your car
What color is your Bike*

What color is your car
Can your car be fixed or do you think it is a total loss?*
- I think my vehicle can be fixed rather than a total loss.
- I think my vehicle is a total loss from this collision.
Can your bike be fixed or do you think it is a total loss?*
- I think my bike can be fixed, rather than totaled.
- I think my bike is a total loss and should not be repaired.
Was your vehicle towed from the scene?*
- Yes. My vehicle was towed from the scene.
- No. My vehicle was not towed from the scene.
Was your motorcycle towed from the scene?*
- Yes, my bike was not rideable and was towed from the scene.
- No, I was able to get my bike home from the scene.
Where is your car now? Is it still accruing storage charges?*

Is your car or bike still accruing storage charges?
Where is your bike now? Is your bike accruing storage charges?*

Is your car or bike still accruing storage charges?
Recorded Statements:
Have you given anyone a Recorded Statement?*
- No, no one has taken any sort of recorded statement from me
- Yes, I gave a recorded statement to my insurance company
- Yes, I have given a recorded statement to the other parties insurance company
- Yes, I have given a recorded statement but I don't know who it was.
Who did you give a Recorded Statement to?*
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?
Has anyone from "Risk Management" contacted you?*
- Yes. Yes, Risk management has contacted me.
- No. No, Risk management has not contacted me.
Who from Risk Management has contacted you*
First Last
Phone number for Risk Management
What has Risk Management Told you or asked you?
End of Property Damage MVA
Beginning of Client Assessment and lifestyle
Marital Status*
Name of Spouse, Ex, or Partner*
First Last
How many Children do you have?*
- None. I have no children
- One minor child
- Two minor children
- Three or more minor children
- One adult child
- Two adult children
- Three or more adult children
Have you filed your income tax returns in the past?*
- No. I have not filed tax returns in the past 5 years.
- Yes, I have filed my tax return for 5 years or more
- Yes, but less than five years
What are the circumstances of your not filing taxes?*
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.
Do you have copies of your income tax returns?*
- Yes. I have copies of my past tax returns.
- No. I do not have copies of my tax returns.
What is the name of the person or company that prepared your tax returns?*
First Last
What is the highest level of education that you have achieved*
Have you ever been in the military?*
- Yes. I have been in the military, or I am still in the military.
- No. I have never been in the military.
I DO NOT EXPECT THIS QUESTION TO WORK WELL. I created a condition that the age of the person is greater than 18. But I don't think the computer can calculate age. So, this is a TEST. If it works, great, if not, change the conditional logic, to type of case.
Were you honorably discharged from the military?*
- Yes. I have been discharged from the military with an honorable discharge.
- No. I have not been honorably discharged from the military.
Have you ever had your drivers license suspended or revoked?*
- Yes, I have had my drivers license suspended or revoked, now or in the past.
- No. My drivers license has never been suspended or revoked.
Have you ever been arrested?*
- Yes. I have been arrested in the past.
- No. I have never been arrested.
Why, when and what were you arrested for?*
Please tell us about any and all arrests
Have you ever been convicted of a felony*
- No. I have never been convicted of a felony.
- Yes. I have had a felony conviction.
How many Felony Convictions, what year, what state and county*
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.
Have you ever been convicted of a Misdemeanor involving theft, false statments or dishonesty*
- Yes. I have been convicted of a Misdemeanor involving theft, false statements or dishonesty.
- No. I have ever been convicted of a Misdemeanor involving theft, false statements or dishonesty.
shop lifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
How many Misdemeanor Convictions, what year, what state and county*
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.
Are you thinking about filing for Bankruptcy now or in the future?*
- Yes. I am considering filing bankruptcy now or in the future.
- No. I have no reason to file bankruptcy now or in the future.
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.
Have you ever hired a lawyer before this claim?*
- No, you are the first lawyer I have ever hired
- Yes, I have had prior accident or injury cases
- Yes, I have had prior workers compensation cases
- Yes Bankruptcy
- Yes, Divorce
- Yes, Criminal
- Yes, Other
My other claim is:*
NEEDS A GOOD LOCATION THIS QUESTION LOST ITS SPOT SHOULD FOLLOW "Do you have any other pending pclaims going on now?"
Have you consulted with other attorneys about this case?*
We would like to know if you have sought legal representation before calling us?
If you have an attorney already, why are you calling us?*
- I am dissatisfied with my attorney that I have now
- I want a second opinion about my legal rights
- My attorney told me that they don't want to go any further with my case and told me to find someone else to take my case
The reason I am seeking a second opinion or unhappy with my lawyers is:*
- I have never met my attorney
- My attorney has failed to communicate with me
- My attorney is not meeting my expectations
- My attorney seems hesitatnt to take my case to trial
- Other
Are you firing your attorney for good Cause?*
- Yes. I have good cause to fire my present attorney.
- No, I don't have just cause to fire my attorney, I just want to change attorneys and understand I will have two attorney fees to pay.
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.
What is the name of your attorney you have now that you want to fire*
First Last
Address of your attorney you want to fire*
Street Address City State ZIP Code

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.
Before hiring your attorney you have now who you are considering firing, how many other attorneys have you hired for this claim?*
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.
What is the name of the first attorney you hired before the one you are about to fire?*
First Last
What is the address of the first attorney you hired*
Street Address Address Line 2 City State ZIP Code
What is the name of the Second attorney you hired before the one you are about to fire?*
First Last
What is the address of the second attorney you hired*
Street Address Address Line 2 City State ZIP Code
What is the name of the Third attorney you hired before the one you are about to fire?*
First Last
What is the address of the Third attorney you hired*
Street Address Address Line 2 City State ZIP Code
Do you have any other Pending Injury Claims that are going now?*
- No. I have no other claims for any injuries going on now.
- Yes, I have another Injury claim that is going on now with another attorney
Are you bringing any other personal injury claims other than this one?
What is the name of your attorney handling the other claim?*
First Last
What is the address of the attorney handling your other claim?*
Street Address City State ZIP Code
Prior Lawyers Names, Address and reasons you hired them.*
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?
Is there anything else you think we should know about you or your claim that has not been covered above?
Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.

Save and Continue Later

End of contact information for Main Contact, beginning of contact for other person who is injured or deceased

Beginning of Work History and Loss of Earnings for the Injured Person.

End of Client Work History --- DATE OF LOSS

Beginning of LIABILITY

Witness Identification who may be a witness?

End of ID of people in Clients car / Beginning of description of the Incident

EVIDENCE Section Break Marker to help me find location in form

End of Evidence and photographs. Beginning of Injuries

Beginning of Clients UM and Other Insurance coverage

End of UM and Other Insurance coverage

PIP Questions to find out which PIP policy you can get

You have No PIP insurance to pay your medical bills or lost wages

Your PIP Insurance will pay your medical bill and wage benefits

End of PIP beginning of At Fault Insurance

Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information

End of Health Insurance

Beginning of Property Damage MVA

Recorded Statements:

End of Property Damage MVA

Beginning of Client Assessment and lifestyle