Morgan & Morgan, P.A.

20 North Orange Ave.

Suite 1600

Orlando, FL 32801

(407) 420-1414

QUESTIONNAIRE

The following interview report is for the use of our office only in preparing and evaluating your claim.

The answers you give here are for our use only, they will be held strictly confidential, and will not be released to unauthorized persons.

Please answer every question fully and accurately. All of the questions asked are important. If more space is needed, use the reverse side of the other sheets.

INFORMATION SHEET

  1. Full Name:
  2. Address:
  1. Telephone number:
  2. Age: Date of Birth:
  3. Social Security Number:
  4. Employer:
  5. Address:
  1. Present job title and duties:
  2. Worked there how long?
  3. Business telephone number:
  4. Rate of Pay:
  5. If you were not working for this employer at the time of your accident, please state the following:
  1. Name of employer:
  2. Address of employer:
  1. Job title and type of work:
  2. Rate of pay:
  3. Hours per week:
  4. When left this employer:
  5. Why left this employer:
  1. List prior employment for past ten (10) years:

NAME

/

ADDRESS

/

DATE OF EMPLOY

/

JOB

  1. Please list the names and relationship of all persons residing in your household at the time of the incident.
  1. Please list the number of motor vehicles in the household and name the owner at the time of the incident.

SPOUSE’S INFORMATION

  1. Spouse’s full name:
  2. Age:Date of Birth:
  3. Employer:
  4. Address:
  1. Occupation:
  2. Worked there how long?

CHILDREN’S INFORMATION

  1. Children (for each):

NAME
/
AGE
/
DATE OF BIRTH
/ LIVING W/YOU NOW
  1. Do you wear glasses, contact lenses or hearing aids? If so, who prescribed them; when were they prescribed; when were your eyes or ears last examined; and what is the name and address of the examiner?
  1. Have you ever been convicted of a crime, other than any juvenile adjudication, which under the law under which you were convicted was punishable by death or imprisonment in excess of one year, or that involved dishonesty or a false statement regardless of the punishment? If so, state as to each conviction, the specific crime, the date and the place of conviction.

ACCIDENT INFORMATION

  1. Accident Date:
  2. Day of Week:
  3. Time:A.M. / P.M.
  4. Location (be specific):
  1. Describe details of accident (including what happened to you, physically at the time of the accident):
  1. If you were injured in an auto accident, were you wearing your seat belt?
  2. Did any mechanical defect in the motor vehicle in which you were riding at the time of the incident described in the complaint contribute to the incident? If so, describe the nature of the defect and how it contributed to the incident.
  1. Were you actually on-the-job at the time of your accident?
  2. Were you on the way to or from work?
  1. Were you charged with any violation of law (including any regulations or ordinances) arising out of the incident described? If so, what was the nature of the charge; what plea, or answer, if any, did you enter to the charge; what court or agency heard the charge; was any written report prepared by anyone regarding this charge, and if so, what is the name and address of the person or entity that prepared the report; do you have a copy of the report; and was the testimony at any trial, hearing, or other proceeding on the charge recorded in any manner, and, if so, what was the name and address of the person who recorded the testimony?

MEDICAL HISTORY

  1. Were you suffering from physical infirmity, disability, or sickness at the time of the incident? If so, what was the nature of the infirmity, disability, or sickness?
  1. List the names and business addresses of all other physicians, medical facilities or other health care providers by whom or at which you have been examined or treated in the past ten years; and state as to each the dates of examination or treatment and the condition or injury for which you were examined or treated (including hospitalizations).

DATE
/
HOSPITAL
/
DOCTOR
/
DURATION
/

NATURE OF ILLNESS

  1. Have you had any physical examinations before this accident? If so, list all physical examinations for five (5) years before the accident:

DATE
/
PLACE
/
NAME OF DOCTOR
/
PURPOSE
  1. Have you had any accidents or injuries before this accident? If so, list every such accident or injury whether there was a claim for damages or not. Please be specific.

DATE
/
PLACE
/ NATURE OF ACCIDENT OR INJURY / TREATED BY:
  1. Have you had any chronic health problems? If so, list them below?
  1. Did you consume any alcoholic beverages or take any drugs or medication within twelve hours before the time of the incident? If so, state the type and amount of alcoholic beverages, drugs or medication that were consumed and when and where you consumed them.
  1. Have you ever had any insurance of any kind declined or canceled? If so, give the reasons.
  1. Have you ever had any broken bones? If so, give date and circumstances:
  1. List below what normal activities including sports, hobbies, or other activities you enjoyed before the accident.

DAMAGES FROM THE ACCIDENT

  1. State in full detail all injuries you received as a result of this accident:
  1. State your present physical condition, scars, deformities, headaches, pains, etc. due to the injuries received in this accident?
  1. Has anything been paid or is anything payable from any third party for the damages listed in your answers to these interrogatories? If so, state the amounts paid or payable, the name and business address of the person or entity who paid or owes said amounts, and which of those third parties have or claim a right of subrogation. (Please list all health insurances covering you at the time of the incident and any health insurance company covering you at the present time)
  1. Have you missed any time from work as a result of your injury? If so, list the inclusive dates you were unable to work:
  1. Do you contend that you have lost any income, benefits, or earning capacity in the past or future as a result of the incident described in the complaint? If so, state the nature of the income, benefits, or earning capacity, and the amount and the method that you used in computing the amount.
  1. Have you had any increase or decrease in your pay since your accident? If so, explain.
  1. List all the hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in the accident, the dates and the total costs, (please include all medical facilities referred by your treating doctor):
  1. Hospital

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. Hospital

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. Hospital

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. List the full name, address and telephone number of each physician or surgeon who has examined or treated you for your injuries as a result of the accident, the dates and the total costs (please include all physicians referred by your treating physician):
  1. Doctor’s Name:

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. Doctor’s Name:

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. Doctor’s Name:

Address:

Telephone Number:

Type of Treatment:

From:To:

Total Cost:

  1. Has any doctor given you a disability that kept you off of work? If so who? Do you have a copy of the disability slip?
  1. List here all of your usual activities which you have not been able to perform, or can only perform with difficulty since the accident, such as climbing stairs, ironing, cutting grass, dancing, lifting children, etc. Please be specific.
  1. Please summarize your out-of-pocket expenses, and if you have not previously given us the name and address, indicate to who they are owed, as well as the amounts, and whether they have been paid:

CLAIMS AND LAW SUITS

  1. Have you ever been involved in any claim or lawsuit including divorce? If so, list below every claim you have made for money or law suits you have ever been involved in:

DATE
/
PLACE
/ AGAINST WHOM / NATURE OF CLAIM /
RESULT

EDUCATION

  1. Please give your educational background, listing names of schools attended and years attended, and any degrees obtained:
WITNESSES
  1. List the name, address, and telephone number of all witnesses to the accident in question (persons who saw or may have seen the accident), and any other person who may be of assistance in testifying about your case, your injuries, or changes in your activity since the accident.
STATEMENTS MADE
  1. Have you ever told any investigator, insurance adjuster or any other person about the incident?
  1. Have you given any written statement to any person about the incident? If so, answer the following.
  1. Name of person to who statement was given:

Date Given:

If written, do you have a copy?

Persons present at time:

Did you sign the statement?

  1. Name of person to who statement was given:

Date Given:

If written, do you have a copy?

Persons present at time:

Did you sign the statement?

  1. Please give us any statement you know the defendant made about the incident, or that you understand that he may have made:
CONCLUSION
  1. In completing this questionnaire, have you thought of any information which we have not asked which may be of some assistance to us in serving you? If so, please state it here no matter how silly, trivial or embarrassing it may seem.

DATED this ______day of ______, ______.

I have read the above statement and the statements contained therein are true and correct.

Please Sign Here

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