What type of case is this?
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.
Thank you for sharing with us how you found MattLaw.
Please tell us the name of the Attorney who referred you to MattLaw
Med Mal Alive
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
Med Mal Alive
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.
Med Mal Wrongful Death
Med Mal Wrongful Death
Med Mal Wrongful Death
What is the date of birth of the child that can bring a wrongful death medical malpractice case
Med Mal Wrongful Death
Med Mal Wrongful Death
What is the date of birth of the child that can bring a wrongful death medical malpractice case
Med Mal Wrongful Death
Med Mal Wrongful Death
What is the date of birth of the child that can bring a wrongful death medical malpractice case
Med Mal Wrongful Death
Med Mal Wrongful Death
What is the date of birth of the child that can bring a wrongful death medical malpractice 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
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This is the address where we will mail any documents relating to the case.
Enter their Cell Phone Number here
What is your Facebook web address? Example https://Facebook.com/MattLaw
Enter the person's birth date
Person's Age
Please enter the name and any other information of who we can contact if for any reason we cannot contact you.
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
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.
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Where does the injured person reside, or if they are deceased their last address
Which county did the death occur in? Where do we get the death certificate?
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.
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.
Please give us the names, ages and relationship to the deceased of minor children, adult children, parents, brothers, sisters or surviving spouse.
If a formal guardianship has been created please provide the details regarding the Court that established the guardianship, dates, etc.
If there is additional information about the injured person that did not fit in the boxes above, add that information here please.
Beginning of Work History and Loss of Earnings for the Injured Person.
Where do they work
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Enter the Employer's Address Here
Workers Compensation
Workers Compensation.
If the company had a business name other than its legal name, tell us what name they used to do business.
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Workers Compensation
Workers Compensation
Workers Compensation
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Workers Compensation
Workers Compensation
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Workers Compensation
Workers Compensation
How much are you paid?
How long have you been unemployed?
What was your last employment before becoming unemployed.
Workers Compensation
Workers Compensation
What year did you retire?
What year did you become disabled?
Where are you attending school?
If there is additional information 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.
Workers Compensation
What is the date you believe the malpractice happened?
Med Mal Alive
When was the first time you thought that some doctor or medical person made a medical mistake causing you harm?
NURSING HOME ABUSE:
NURSING HOME
When was the first time you thought that there was nursing home neglect, abuse, or violation of their rights?
NURSING HOME ABUSE:
Med Mal Alive
Med Mal Alive
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.
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.
If the client has been involved in a second accident, this field will show up and you enter the second DOA here.
MOTORCYCLE AND BICYCLE
MOTORCYCLE AND BICYCLE
MOTORCYCLE OR BICYCLE
OTHER TYPES OF CLAIMS:
Describe in your own words what happened and who you blame for the losses?
Beginning of LIABILITY
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.
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
NEGLIGENT SECURITY
Select the areas that describe the surroundings where the security was inadequate
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
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
NEGLIGENT SECURITY
Check all that may apply to your attack
NEGLIGENT SECURITY
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.
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?
NEGLIGENT SECURITY
How familiar were you with your surroundings where this attack happened?
NEGLIGENT SECURITY
PRODUCTS LIABILITY
PRODUCTS LIABILITY
PRODUCTS LIABILITY
PRODUCTS LIABILITY
PRODUCTS LIABILITY
PRODUCTS LIABILITY
NURSING HOME ABUSE:
NURSING HOME ABUSE:
NURSING HOME ABUSE:
If you know of any violations of any of these laws, check the box and then explain the violation below.
NURSING HOME ABUSE:
What is the name of the facility that you blame for the abuse or neglect?
NURSING HOME ABUSE:
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.
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?
Med Mal Alive
Med Mal Alive
Workers Compensation
Slip and Fall
Select the County where the accident happened
Pharmacy Negligence
What is the name of the Pharmacy that made the mistake?
Pharmacy Negligence
What is the address, or the street and cross street and city where the pharmacy is located.
Pedestrian v MVA accident:
We would like to know what the area where you were injured was like regarding sidewalks, cross walks, driveways etc.
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.
Pedestrian v MVA accident:
Slip and Fall
Were you shopping, making a deposit, exercising? What was your purpose you wanted to accomplish before falling?
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall or Trip and Fall question
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.
Slip and Fall
Slip and Fall
Describe the bottom of your shoes
Slip and Fall
Describe the material the soles of your shoes were made out of
Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
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If you were a passenger, was the driver of your car at fault?
Motorcycle Crash
Motorcycle Crash
Bicycle Crash
Bicycle Crash
Bicycle Crash
Bicycle Crash
Bicycle Crash
Please stop riding the bike, save it as evidence we can use at trial if needed.
Bicycle Crash
Motorcycle Crash
Motorcycle Crash
Motorcycle Crash
Motorcycle Crash
Motorcycle Crash
Motorcycle Crash
Anything else that may be of interest, such as wearing a back pack, scarf around your face or neck.
Pedestrian v MVA accident:
Motorcycle Crash
Describe what you saw before the impact.
Did your car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Describe what was wrong with your vehicle
Was anyone intoxicated during the accident?
Was anyone intoxicated during the accident?
Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the at fault driver do? Why are they the one at fault for this collision?
Motorcycle Crash
Bicycle Crash
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.
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?
We are collecting the names of Eye Witnesses, and or Companions to your case.
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What is the name of the first eye witness who you have not told us about already?
What is the name of the first eye witness who you have not told us about already?
How can we get in touch with any eye witnesses so we can ask them what they remember about this.
End of ID of people in Clients car / Beginning of description of the Incident
Help us save, and preserve this evidence. We want to photograph it, measure how much was left, and help prove how much you took.
Pharmacy Negligence
Did they ask for it back and you complied? Did you throw it away, if so, when and why?
Enter what their ticket was for. For example, following too closely
If you got a traffic citation, what was it for?
Which vehicles left skid marks, which vehicles left gouges in the road, how long were they, where were they located?
EVIDENCE Section Break Marker to help me find location in form
Evidence
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
Pedestrian v MVA accident:
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
Tell us about anything else we might want to photograph, or obtain to help prove your case?
End of Evidence and photographs. Beginning of Injuries
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?
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?
Tell us about any medical treatments, hospitalizations, surgeries therapies that you have had after the pharmacy mistake.
Med Mal Alive
Please provide the names, addresses and phone numbers of your treating doctors that you are seeing now on a frequent basis.
Med Mal Alive
Med Mal Alive
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?
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?
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?"
Tell us the name of the Fire Rescue department so we can order the records.
NEGLIGENT SECURITY
Did any medical person use a Rape Kit to collect DNA samples from you after the attack?
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.
Motorcycle, Bicycle Crash or Pedestrian Accidents Only
Workers Compensation no death
Workers Compensation
What other injuries or physical or psychological problems are you having that you relate to this 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.
Injuries
Please list the medications that you have been prescribed, the name of the medication, the strength of the medication and where you got the prescription filed.
Example: Flexeril, 80mg as needed, filed at CVS pharmacy on Waters Avenue in Tampa. Or, None, if you don't have any prescriptions.
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.
We may want to order these records so that we can make sure your treating doctors know about your prior conditions so they can factor them into your health care plan.
Please tell us each and every hospital you have been seen in over the past 10 years. Including short visits like an Emergency room and released, to long term admission as a patient.
Have you ever seen a chiropractor, even for one visit before this incident?
We need the name, address and approximate date that you saw chiropractors before this accident. Also, it may be a good idea for you to return to them to be seen as a Before and After Doctor to help prove your case.
Have you ever seen a psychiatrist, psychologist, or been baker acted before this incident?
We need the name, address and approximate date that you saw any mental health professionals before this accident.
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Have you been given a work disability slip from anyone because of your injuries from this car crash?
Help us figure out how much work you will miss because of your injuries from this incident. You can say in hours, days, weeks or years.
Please give us the name and location of the doctor that has taken you off of work. We need to order your records
Please calculate as best you can what amount of money you have lost so far as a result of this crash?
Beginning of Clients UM and Other Insurance coverage
Are any of your policies from out of the State of Florida? We need to know this so that if you have an out of state policy, the coverage's may be different that typically required by Florida Law.
If you don't have a Florida insurance policy, which state is the policy from?
If you know your limits please indicate this, if you don't know, put Unknown
What are the limits on your UM policy?
Stacked UM coverage gives you more benefits. Also, they can be stacked even if they are with different insurance companies, and sometimes even on some motorcycle policies.
What is the total number of motor vehicles that you own that may provide UM coverage to you?
Do you happen to have different insurance companies for different vehicles? If so, we want to contact them all and find out if there are any other UM policies to cover your losses.
Provide your Umbrella Policy Number if known, if you don't know, enter Unknown
If you have Stacked UM Umbrella Insurance please let us know.
Please give us the name and phone number of your Insurance Agent so we can see what other coverage's you might have to protect you and your family.
End of UM and Other Insurance coverage
PIP Questions to find out which PIP policy you can get
Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage.
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.
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.
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.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
You 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.
Enter the claim number or if you don't have one enter Unknown.
If yes, they get PIP from the owners policy. If no, they are out of luck, no PIP
We need the name of the rental company so that we can find out what insurance was taken out that may protect you.
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?
Was the insurance in your name?
End of PIP beginning of At Fault Insurance
This is where we start recording that At Fault Insurance Company information.
Slip and Fall
Did you notify the owner or management or any employee about the incident?
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
Slip and Fall
Slip and Fall
Did they give you a copy of the accident or incident report?
Slip and Fall
Did the manager or store or anyone have you sign anything such as an accident report or medical release authorization?
Slip and Fall
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. . .
Slip and Fall
Slip and Fall
Tell us the name of the insurance company. If you don't know, just put "unknown"
Slip and Fall
Slip and Fall
Slip and Fall
Slip and Fall
Do you think they have any surveillance video of you in and around the area?
Slip and Fall
What else would help us contact that at fault party, contact any witnesses, or help document whose fault this was?
Pharmacy Negligence
Pharmacy Negligence
Name of medication, quantity of medication, like so many milligrams, and frequency of the medication, how often were you to take it?
Pharmacy Negligence
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."
Pharmacy Negligence
Pharmacy Negligence
***Note, this may be a redundant question***
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Name of the At Fault Insurance Company
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
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Name of the Insurance Company for the Owner of the vehicle that was at fault.
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Who was the driver working for when he caused the crash? We will sue his employer also.
Explain why you think the bad driver was working or running an errand for someone else when the crash occurred? We want to know to seek additional insurance coverages for you.
Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information
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?
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.
Do you have any type of Health Insurance?
This date is on your health insurance card and it tell us when your coverage first began.
Do you have any type of Medicare Insurance or supplements? Medicare is generally for people over the age of 65, or if the person is on Social Security Disability.
What is the name of Part A
We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part A has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part B Medicare Insurance Company
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part B has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part C Medicare Insurance Company
This date is on your Medicare insurance card and it tell us when your coverage first began.
We need to know if medicare part C has paid any money to help with your care as a result of this incident?
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
This date is on your Medicare insurance card and it tell us when your coverage first began.
We need to know if medicare part D has paid any money to help with your care as a result of this incident?
Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
This date is on your Medicade insurance card and it tell us when your coverage first began.
We need to know if Medicaid has paid any money to help with your care as a result of this incident?
Medicaid is only available to poor people, not related to age.
Wellcare is available to children and adults of low income, and may not have Medicare Parts A, B or C. We need to know what bills if any Wellcare has paid.
It might be called just Wellcare, and it may be managed by another company. We need the company name.
This date is on your Medicade insurance card and it tell us when your coverage first began.
We need to know if Wellcare has paid any money to help with your care as a result of this incident?
Wellcare is only available to poor people, not related to age.
What is their address or contact information for Medicaid?
If you have any disability insurance that may pay you benefits please let us know about them.
Did you receive any payments for short term or long term disability? If so, we need to contact your disability insurance companies to know what their lien is.
Any notes about any sort of collateral source, which is some other company paying any sort of related bills for lost wages or medical treatments. AFLAC would be included here as well. Get copies of any insurance cards
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
What kind of car was damaged in this crash?
What kind of bike was damaged in this crash?
What color is your car
What color is your car
Is your car or bike still accruing storage charges?
Is your car or bike still accruing storage charges?
Recorded Statements:
We want copies of any recorded statement you may have made, or any court appearance you have made. Please tell us when you gave the recording and to whom?
End of Property Damage MVA
Beginning of Client Assessment and lifestyle
Why have you not filed your taxes? Maybe you were paid cash? Maybe you did not make enough, maybe you did not know how to file. What ever the reason, please let us know.
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.
Please tell us about any and all arrests
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
shop lifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Filing Bankruptcy may mess up your injury case, but if we know about your filing for bankruptcy before you file, it will help you recover the money, rather than your creditors.
NEEDS A GOOD LOCATION THIS QUESTION LOST ITS SPOT SHOULD FOLLOW "Do you have any other pending pclaims going on now?"
We would like to know if you have sought legal representation before calling us?
If you have a good reason to fire your attorney that has an effect on their ability to recover fees for the work they did.
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We can send him a letter on your behalf terminating him, but we need his address to obtain a copy of your file and send him a letter discharging him from your case.
We need to collect all of your records and often times the first or second attorney has some investigative records that we might need to help prove your case.
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Are you bringing any other personal injury claims other than this one?
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Please let us know the names, addresses and types of prior injury claim attorneys, workers compensation attorneys or any other notes that may help us with your case. What is the status of their representation of you now?
Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.