Hogan Injury Disclaimer

PERSONAL INJURY

Attorney Intake Questionnaire

An injury can make a victim’s life very difficult. Aside from the physical injury, the victim may also suffer emotional and psychological damage because of the injury sustained. Aside from that, there is also the issue of insurance companies, medical practitioners, attorneys and other people that may subject the victim for further questioning.

If you are contemplating on filing a personal injury claim, this form can provide you helpful information on what type of questions will be asked.

Name               ____________________________________________________

Date of birth  ____/____/____

Social security number  _____-____-_______

Address           ___________________________________________

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____________________________________________________

Home phone    (_____) ______-________

Work phone    (_____) ______-________

Mobile phone  (_____) ______-________

E-mail address  ____________________

What is the best method to contact you?  _____________________________________

When would be the best time to contact you?  _________________________________

Married  ____  Single  ____  Divorced  ____  Number of children  ____

If married, spouse’s name  ______________________________________________

Date of you Injury  ____/____/____

Where did your injury occur?  City _____________  State _____  County ____________

How did your injury occur?

_        Aircraft accident

_        Animal bite or attack

_        Assault and battery

_        Defective premises

_        Defective product

_        Police negligence

_        Medical malpractice

_        Motor vehicle accident

_        Slip or trip and fall

_        Water-related accident

_        Other ________________________

Description of how you sustained your injury(ies).  ____________________________________________

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Who do you believe  is responsible or at fault for your injury, and why?  _____________________________

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Please describe sustained  injury(ies).  ____________________________________________________

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Please provide the names of the hospital, doctor, and other medical care providers involved in the treatment of your injuries. Please include, names, telephone numbers, and addresses.

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Current total incurred medical expenses due to injury treatment:  $________________

Projected medical expenses due to injury treatment:  $________________

Please write down  the addresses, names,  and telephone numbers of all injury relevant insurance companies  (including, as applicable, health provider, vehicle insurer,  homeowner’s insurer, disability provider,  etc.).

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Have you lost income as a result of your injuries?  Yes __  Amount $_________  No __

Income before injury   $__________ per ___________

Income after injury     $__________ per ___________

Employer                     ____________________________________________________

Position                       ____________________________________________________

Employer’s address     ____________________________________________________

____________________________________________________

____________________________________________________

Employer’s telephone number  (_____) _______-_________

Employed?   Yes ___  No ___  Tentative return to work date ___/___/___

Will not go back to work  ____

Are you suffering from pain because of your injury?  If so, describe.  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did this injury affect your life? (Example, you are unable to make a living, unable to perform daily tasks on your own, etc.)

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For married claimants, were there any losses your spouse incurred as a result of the injury you sustained. If yes, please describe.  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide the names of people who have witnessed the case. Please include addresses and phone numbers if possible.

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Have you previously consulted an attorney regarding your case?  Yes  ____  No  ____

If yes, provide the attorney’s name(s), the firm name(s), the address(es), and the telephone number(s).  ______________________________________________________

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Is your relationship with the attorney ongoing?  Yes  ____  No  ____

Has an attorney declined to represent you in this matter?  Yes  ____  No  ____

If yes, why?  ______________________________________________________________________

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Do you have questions about your injury case?:

_______________________________________________________________________________

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