About Us
Personal & Catastrophic Injury
Family Law
Forms
Contact Us
Start Your Legal Journey — No Cost Consultation!
Personal Injury Information Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Middle
Last
Date of Birth
*
Drivers License Number
*
State of Issue
*
Social Security Number
Your Social Security Number Is Needed Before Medical Providers Will Release Your Medical Records
– To Number
Primary Telephone
*
Contact Type
Cell
Cell
Home
Work
Secondary Phone Number
Secondary Contact Type
Cell
Cell
Home
Work
Email
*
Client Address (Street Name & Number, City, State, Zip)
*
Employer/Job Title
Have You Lost Time From Work As A Result Of The Incident?
YES
NO
If Yes, What Is Your Current Wage/Salary?
Wage/Salary Type
Hourly
Weekly
Bi-Weekly
Monthly
Yearly
Marital Status
Single
Single
Married
Divorced/Widowed
Emergency Contact Name
*
First
Last
Emergency Contact Address, Telephone, and Email
*
Emergency Contact Relationship To Client
Date of Incident:
*
Time of Incident:
Approximate Time The Incident Occurred
Type of Incident
Automobile Collision
Automobile Collision
Premises/Slip & Fall
Medical Malpractice
Check All That Apply (Auto Collisions)
Passengers In Your Vehicle?
Tractor-Trailer/Commercial Vehicle Involved?
Multiple Vehicles Involved? (More Than 2)
Airbag Deployed?
Alcohol/Drugs Involved?
Citation(s) Issued?
Were You Working At The Time Of The Incident?
YES
NO
Incident Location (Road, County, State)
*
Description of Incident
Did You Speak To Other Drivers At The Scene?
YES
NO
Did Police Arrive At The Scene?
YES
NO
Did You Speak To The Police At The Scene?
YES
NO
Did The Police Determine Who Was At Fault?
YES
NO
Name Of Party At Fault
Did You Take Photos Of The Scene Or Vehicle Damage?
YES
NO
Were There Any Witnesses At The Scene?
YES
NO
Name Of Witnesses
List Names, Telephone Numbers of Any Witnesses to the incident or events immediately after the incident.
Was A Police Report Issued?
YES
NO
Police Report Number
Police Department Name (County/State Patrol)
List The Names Of Any Responding Police Departments Whether City Police, County Police, Or State Patrol.
Name Of Responding Police Officer
List Name(s) Of The Responding Police Officer(s), if any.
Did Any First Responders Arrive At The Scene?
YES
NO
First Responders At Scene
List Departments or Names Of Any First Responders To The Incident Scene. (EMS, Fire Department, Etc.)
Name Of Your Automobile Insurance Company
Your Policy/Claim Number
Have You Given A Statement To Your Insurer?
YES
No
Do You Have Uninsured Motorist Coverage?
YES
No
I AM NOT SURE
Do You Live With Relatives That Have Their Own Auto Insurance?
YES
No
Name Of At-Fault Driver's Insurance Company
At-Fault Driver's Policy/Claim Number:
Have You Given A Statement To The At-Fault Driver's Insurer Or Representative?
YES
No
Do You Have Health Insurance?
No
Yes, But I Am Not Sure What Type
I Have Medicaid
I Have Private Health Insurance
I Have An Exchange Plan
I Have Medicare
I Have TriCare
Health Insurance Company Name
Policy/Member ID Number:
Group Number:
DOD ID Number:
Select All Treatment You Have Received As A Result Of This Incident
EMS/Ambulance
Emergency Room
Urgent Care
Primary Care Physician
Chiropractic Care
Orthopedic Care
Physical Therapy
Pain Management
Xrays/MRI/CAT Scan
Provider 1 – Name/ Contact Information
Provider 2 – Name/ Contact Information (copy)
Provider 3 – Name/ Contact Information
Provider 4 – Name/ Contact Information
Provider 5 – Name/ Contact Information
Provider 6 – Name/ Contact Information
How Did You Hear About Our Firm?
Personal Referral
Facebook
Google
Georgia Bar
Submit
