Personal Injury Questionnaire

Disclaimer:  Completing this form does not create any attorney-client relationship.  Thus, no information provided by you shall be considered confidential or protected by an attorney-client confidentiality until our office is officially and adequately retained as your attorney and allowed a full opportunity to review for any conflict of interest.

Your First Name: 
*

Your Last Name:
*

Your Middle Name (Optional]:

Your Birth Date:

Your Telephone Number:


Your Cellphone Number (Optional):

Best time to call you:

Best day to call you:

Do you have your own auto insurance?

Yes
No

Is this your first time seeking an attorney?

Yes
No

If not, which attorney(s) have you spoken to?


1. Accident Information

Were you the person that caused the accident?

What is your role in the auto accident?

Driver
Passenger -Front
Passenger -Back
Bicyclist
Pedestrian
Spouse of Accident Victim
Family / Friend of Accident Victim

Date of the Accident:

Approximate time of Accident?:


AM PM

Did you use a cellphone or electronic device at the time of accident?

Yes
No

Please describe the estimated extent of damage to your vehicle:

Name of Person that hit you:

Address:

Were you working or performing anything work-related at the time of this accident?

Yes
No

Location of accident:

City: 

State:

What type of road did the accident occur on?:

Freeway
Local Road
Small Residential Street
Bridge
Intersection
Parking Lot
Alley

Describe the weather and road conditions prior to the accident:

Did you or any other person in the vehicle use or ingest any substances that impair the quality of judgment?

Yes
No

Is there a police report?

Yes
No

Was the police report filed by the CHP (California Highway Patrol) or the Local Police?

If Local Police filed the report, which Local Police Department was it that filed the report?

Police Report ID:

Station Phone Number:

Officer Information:

Address of Station:

City:

State:


ZIP Code:

2. Vehicle Information

What car model were you in?

Model:


Make:

Year:

Please describe where your vehicle was hit, and provide details on the extent of the damage:

Please provide any images you may have of your vehicle:

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What car model was responsible for hitting your car? List all of the cars involved:

Model:


Make:

Approximate Year:

Is this a commercial vehicle?

__________________________________________________________________

Model:


Make:

Approximate Year:

Is this a commercial vehicle?

__________________________________________________________________

Model:


Make:

Approximate Year:

Is this a commercial vehicle?

 

3. Medical Information

Was an ambulance called to the scene?

Yes
No

Were you admitted into the Emergency Room / ER?

Yes
No

Please check any injuries that you believe you suffered from this accident, check all that apply:

Whiplash
Cuts & Scrapes
Back Injury
Emotional Trauma
Heart Related Injury
Soreness
Fracture of Limbs
Neck Injury
Psychological Trauma
Internal Bleeding
Bruising
Fracture of Structure
Brain Injury
Memory Loss
Fatality

Please describe where your body is currently injured, and provide details on the extent of your bodily injury:

Please also provide any photos that you may have of your injury:
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Do you currently still experience pain or still suffer from the injury?

Yes
No

4. Personal Loss

Did injuries from the accident prevent you from working?

Yes
No

Do you have documentation of your earnings?

Yes
No

What is your occupation?

Approximately how much do you earn per month?
$

5. Additional Information

Have you been in any accidents before, and if you have, how many?

If you have been in an accident, please provide details:

I acknowledge that the foregoing information I am providing is solely for the purpose of having my case reviewed. I understand that the submission of this information does not form an attorney-client relationship. I certify that the information I have provided in this questionnaire is true to the best of my knowledge and belief.*

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