Personal Injury

New Client Information Form

Identity & Contact Information

Full Legal Name

How would you like to be addressed

What would you like us to call you (e.g., Joe instead of Joseph)

All prior names or aliases

ℹ️ Personal data, including your Social Security number and date of birth, is required for certain insurance claims handling, medical billing/lien resolution, and settlement documentation. It will only be used for case-related purposes and is collected securely through this encrypted portal.

Birthday

Month

Day

Year

Social Security Number

no dashes

Multi-line address

Country/Region

Address

City

Zip / Postal code

State of Residence

County of Residence

County where events took place, if different

Phone Number - preferred

Multi choice

Cell

Home/ Landline

Work

Other

Alternate Phone Number

Type

Cell

Home/ Landline

Work

Other

Please upload a government-issued photo ID

e.g., driver license, state ID card, passport

Health Insurance Carrier

Health Insurance Policy Number

Unless a particular question states otherwise, please understand that all questions refer to the accident and to the injuries and treatment arising directly from that accident.

About the Vehicle You Were In

Year, Make, & Model

Was the Vehicle Drivable?

Yes

Unsure

Was the Vehicle Towed?

Yes

Unsure

Dash camera of video surveillance?

Yes

Unsure

About the At-Fault Driver

Name (first and last)

Insurance carrier (if known)

Policy Number

Policy Limits of Uninsured / Underinsured Motorists Coverage

Terms of Umbrella Coverage, if Applicable

Owner of vehicle (if different from driver)

Your Auto Insurance Information

Auto Insurance Carrier

Policy Number

Policy Limits

If you have MedPay Coverage, Describe Terms or state None.

Treatment

Describe your treatmet plan, including known dates.

Are you currently under active medical treatment?

Yes

I don't know

Do you anticipate additional future care?

Yes

I don't know

Have you been released from care?

Yes

I don't know

Injuries

Did you lose consciousness?

Yes

Has any treating provider told you that your injuries are permanent?

Yes

Do you have any permanent restrictions?

Yes

I don't know

Do you have any of the following:

Deformity

Loss of Range of Motion

Impaired Mobility

Maximum Pain Level (1-10)

10 being worst pain ever.

Describe Your Pain

State time range (if it has stopped or lessened); constant, intermittent

Employment & Lost Wages

Employer name

Job title and description:

How many days have you missed from work?

Brief overview of your employment history over the past ten years. Please list each item using numbers. Example: 1) ABC, Inc. – Position – Dates; 2) Employer B – Position – Dates; 3) Employer C – Position – Dates

Include Employer Name - Job Title - Date Range

Please state your hourly wage or salary:

Disability benefits?

Yes

Unknown

Any future lost earning capacity?

Yes

Unknown

Medical Bills & Liens

Approximate medical bills to date:

Check all that have applied

Damages & Claims Status

Functional Impact

Check all that have applied to you:

An insurance company contacted me

I have given a recorded statement

A settlement offer has been made

I have signed documents with tehe insiurance company about my loss

Have injuries impacted your daily activies as to any of the following? (Check all that apply)

Family, Relationship & Household Information

ℹ️ Why we ask: Household members may later be relevant as witnesses, individuals with knowledge of key facts, or relevant to the harm you/they suffered.

Relationship Status

e.g,. married, widowed, separated, etc.

If applicable, identify any prior marriages or significant relationships that may be relevant—directly or indirectly—to your case, including those that existed during events related to this matter.

Are you currently involved in a divorce, separation, or custody matter?

Household & Minor Children

Please identify (first and last name) all adults residing with you, and their relationship to you. Please list each person with numbers. E.g.,: 1) Sally Mae Smith - sister; 2) Robert Edward Marks - friend; 3) Allison Dee Banks - daughter (Ellie)'s friend

Please identify (first name only) all minors or dependents, including their ages. Please list each person using numbers. E.g., 1) Ellie - 16; 2) Teddy - 7; 3) Billy - 3

Prior Legal History

Prior lawsuits or legal proceedings. Please separately list matter using numbers (e.g., 1, 2, 3, ...) If none, state "none."

As a named party. E.g., plaintiff, defendant, etc.

Past bankruptcies If none, state "none."

State years of each, as applicable.

If you are currently represented by another attorney in any other matter, please describe. If inapplicable, state "NA."

Please list any previous testimony you have given. Please number each instance separately. E.g., 1, 2, 3... If inapplicable, state "NA."

Any testimony under oath at a deposition, hearing, trial, etc.

Social Media & Online Presence

ℹ️ Why we ask: Social media content may become relevant or discoverable in litigation. We do not request any login credentials

List all social media platforms used, including your handle or username on each. Separate each site by number. E.g., 1. Twitter - Sally1843; 2. Facebook - Sally Jensen If inapplicable, state "NA."

e.g., Facebook, Instagram, X, LinkedIn, TikTok, etc.

How are your Privacy settings on social media If inapplicable, state "NA."

Public

Private

It varies on different platforms

I don't know

⚠️ Important Social Media Notice

Please be aware that social media activity may be discoverable in litigation. This means that, in some circumstances, the opposing party may request and obtain information from your social media accounts. We encourage you to be mindful of what appears on your social media accounts while your matter is pending. As a general precaution, you may also wish to review and use heightened privacy settings to reduce unintended access to your content.

If you have questions about social media use during your case, please raise them with our office so we can provide you with guidance tailored to your situation.

Practical Considerations

Please describe any accessibility needs or accommodations for in-person appearances. If inapplicable, state "NA."

Please list any upcoming travel or extended unavailability. If inapplicable, state "NA."

Please keep our office informed if this changes in the future.

I understand information shared on this form is material to my case, and I affirm that the information I have provided is true and accurate to the best of my knowledge.

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