Personal Injury Intake Form
Client Information
Full Legal Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Information
Marital Status:
Single
Married
Divorced
Widow
Date of Birth
 -
Month
 -
Day
Year
Date
Spouse's Name/Significant Other
First Name
Last Name
Children's Names/Ages
*
Drivers License Number
Name of Emergency Contact
First Name
Last Name
Relationship
Emergency Contact Information
Please enter a valid phone number.
Format: (000) 000-0000.
Prior Criminal Record:
Yes
No
If yes, please explain.
Accident Information
Date & Time of Accident
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Statue of Limitations
Location
How did the accident happen?
Passengers in Vehicle
*
Investigated by Police?
Yes
No
Incident Number
Statements given?
Yes
No
If yes, to whom?
First Name
Last Name
Injuries
Injuries Sustained in this Accident
Prior Injuries
Pre-Existing Conditions
Medical Conditions/Diseases
Client's Insurance Information
Insurance Company
Agent's Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Number
Claim Number
Liability Coverage?
Yes
No
If yes, how much?
Under/Uninsured Coverage?
Yes
No
If yes, how much?
Medical Payment?
Yes
No
If yes, how much?
Collision?
Yes
No
If yes, how much?
Rental?
Yes
No
If yes, how much?
Claims Adjuster
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Med-Pay Adjuster
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Vehicle Information
Year
Make
Model
Color
Mileage
Name of Towing Company
Client's Health Insurance Information
Name of Insured
First Name
Last Name
Insurance Company
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Policy Number
Group Number
Identification Number
Type of Coverage
Medicare?
Yes
No
Medicare Number
Medicaid?
Yes
No
Medicaid Number
Medical Treatment Information
Ambulance?
Yes
No
Name of Ambulance Service
Emergency Room?
Yes
No
Name of Emergency Room
Who has paid your medical bills?
First Name
Last Name
Treating Physician
First Name
Last Name
Date of Service
 -
Month
 -
Day
Year
Date
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Property Damage Information
Property Damage Already Collected on Your Vehicle?
Yes
No
Do you have an estimate for property damage?
Yes
No
Do you have pictures of your vehicle?
Yes
No
Lost Wages
Did you miss work as a result of this accident?
Yes
No
Employer
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
If so, can you verify your lost wages?
Rate of Pay
Paid how often?
Defendant's Insurance Information
Defendant's Insurance Company
Policy Number
Claim Number
Full Legal Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Drivers License Number
Owner of Vehicle
First Name
Last Name
Relationship
Bodily Injuriy Adjuster's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Property Adjuster's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Any Additional Notes or Information
Other Important Information and Notes
Submit
Should be Empty: