Please detail your question here:

HELPFUL HINTS
The following list of questions will help you organize events and information related to an accident and/or incident:

Date and Time:

CLIENT INFORMATION
Name:

Phone:

Mailing address :

Relationship:

FACTS OF THE MATTER
Type of Case:

Date of Incident:

Injuries:

What Happened?:

Have you contacted another attorney?
YES
NO

If yes, who?

REFERRAL SOURCE
Television
Yellow Pages
Newspaper
Attorney
Past/Present Client
Other Client
Other

ADVERSE INFORMATION

Adverse Party:

Adverse Insurance:

Adjuster's Name:


Contact with adverse insurance?
YES
NO

Liability
Poor
Excellent

TREATMENT

Medical Provider(s):


Hospitalized?
YES
NO

Medically stationary?
YES
NO

Approximate amount of specials:

ISSUES AND COMMENTS: