the McKnight Law Firm
2800 South Hulen Street, Suite 115
Fort Worth, Texas 76109
Telephone (817) 698-9400
Facsimile (817) 698-9401
SOL:__________
PERSONAL INJURY/AUTO ACCIDENT
INTAKE SHEET
INITIAL CLIENT STATEMENT
Instructions: Please complete the form below to the best of your ability and either fax it in or e-mail to: . If you do not know the answer to a question please leave it blank and go to the next question. The information provided will help us efficiently evaluate your case. Thank You.
HOW DID YOU HEAR ABOUT OUR OFFICE OR WHO REFERRED YOU: (INDIVIDUAL, YELLOW PAGE AD, ETC…)
________________________________________________________________________
PERSONAL INFORMATION:
NAME: ______________________________________________________________________
Address: ______________________________________________________________________
City:__________________________________________________ Zip:____________________
Telephone # (home)________________________ (cell/pager) ___________________________
(work) _________________________ (email address) _________________________________
Age: ________ Date of Birth: ________________ Social Security # _____________________
License # _________________________
EMPLOYER: _________________________Address_________________________________
Rate of pay: (hourly, weekly, monthly)____________________Occupation_________________
SPOUSE’S NAME: _______________________________Work phone___________________
EMERENCY CONTACT:
Name: ______________________________ Address: ____________________________
Relationship: _________________________ Phone: _____________________________
CHILDREN:
Name(s)/Age(s):____________________________________________________________________________________________________________________________________________________________________________________________________________________________
EDUCATION:
High School/G.E.D. __________ Year of Graduation: _______________________
College/University: _________________________ Years & Degree: ________________
ACCIDENT INFORMATION:
Accident date: ________________ Day of week: ___________ Time: ________(am/pm)
Location: (Be Specific) _____________________________________________________
________________________________________________________________________
Where were you coming from? ______________________________________________
Where were you going? ____________________________________________________
DETAILS OF ACCIDENT:
Weather condition (if happened outside) _______________________________________
Any construction in the area? _______________________________________________
DESCRIPTION OF ACCIDENT: (BE SPECIFIC—GIVE AS MUCH DETAIL AS POSSIBLE) ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Were you or the adverse driver driving an employer company vehicle?_____________________
What was the make, model, and year of the vehicle you were driving? _____________________
______________________________________________________________________________
What was the make, model and year of the other vehicle? ______________________________
____________________________________________________________________________
Had anyone, including yourself, been drinking? ______________________________________
Did anyone make a statement at the scene? What was said?______________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were photographs taken of the scene? ______________________________________________
INSURANCE COVERAGE FOR YOUR VEHICLE
Name of Carrier: _______________________________________________________________
Policy Number: ________________________________________________________________
Agent’s Name, Number & Address: ________________________________________________
_____________________________________________________________________________
Do you have Uninsured Motorist Coverage or Personal Injury Protection Insurance: __________
Where you on the job at the time of the Accident? _____________________________________
Did you file a claim with your or the adverse driver’s insurance company? _________________
Has anyone from any insurance company contacted you about this claim? _____
Name of Person who contacted you:________________________________________________
When was contact made? ___________________________________________________
If a statement was given, was it tape recorded or written? _________________________
Did you receive a copy? __________________________________________________________
Have you signed any authorizations to release information to anyone? _______________
Have you received any insurance benefits? _____________________________________
INSURANCE COVERAGE FOR ADVERSE DRIVER
Name of Carrier: _________________________________________________________
Policy Number: __________________________________________________________
Agent’s Name, Number and Address: _________________________________________
________________________________________________________________________
Have you spoken to the Insurance company for the Adverse Driver? If so when and to Whom?
___________________________________________________________________________
MEDICAL INFORMATION
Were you injured in this accident? Describe: ___________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Did you go to the hospital? _____Which hospital? _______________________________
Admitted or OPD? _____________ If admitted, when released? ____________________
X-Rays taken? _________________ Were you taken by ambulance? ________________
Are you under the care of a physician now? ____________________________________
Please list all Doctors or Medical facilities including ambulances of any kind you have seen as a result of this accident.
1. Name: ___________________________________ Phone: __________________
Address: _____________________________________________________________
2. Name: ____________________________________ Phone: __________________
Address: _____________________________________________________________
3. Name: _____________________________________ Phone: _________________
Address: _____________________________________________________________
4. Name: ______________________________________ Phone:________________
Address: _____________________________________________________________
Was anyone else injured in the accident? If so Whom? ______________________________
NAME AND ADDRESS OF ALL PARTIES INVOLVED, INCLUDING PASSENGERS:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If you have sustained injuries similar to the ones sustained in this accident on a prior occasion or have seen a doctor for injuries or treatment for the same or similar injuries please describe the injury:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prior claims and/or settlements (types, dates, attorneys):_________________________________
WITNESSES:
Name & address of any witness: ________________________________________
_____________________________________________________________________
Telephone Number: ____________________________________________________
Do you have photos of the scene and auto? __________________________________________
DIAGRAM OF HOW THE ACCIDENT OCCURRED.