Please review the required documents here before starting the intake form.

I.Client Information

Maiden Name/Alias *

Full Name *

Email *

Phone *

Marital Status

Address

Address *

City *

State *

Postal code *

Date of birth

Driver License State & Number *

Upload copy of DL *

Social Security Number

Name of Emergency Contact *

Relationship of Emergency Contact *

Phone Number of Emergency Contact

Prior Criminal Record *

If yes, specify whether it is a misdemeanor or a felony. *

Do you have a bankruptcy pending and/or a child support lien? *

If Yes Please Explain *

How Did You Hear About Us?

Do you use Social Media?

List All

Employer Missed Work *

Who is the employer & What is the rate of pay? *

II. Accident Information

Date of Accident

Time of Accident *

Location *

Number of Vehicles Involved *

How Did Accident Happen? *

Passengers *

If Yes, Name, Phone Number, relation to person filling out this intake *

Wearing a Seatbelt?

Airbags Deployed?

Investigated by Police? *

If so, which police department?

Accident Report Obtained? *

If so, Please upload accident report

Statements Given to Anyone? *

If so, Statement given to whom? *

Prior Legal Representation for This Accident

If yes, Who (Prior Legal Representation for This Accident)

Attorney Name & Phone

III. Property Damage

What is the year, make, and model of your vehicle?

Is your vehicle drivable?

Was your vehicle towed?

If Yes, where was it towed to?

Where is your vehicle currently located?

If so, please Upload Estimate *

IV. Your Insurance Information

Name of Policy Holder (Your) *

Insurance Company (Your) *

Specific to CAR insurance company. Upload copy of insurance card

Policy Number (Your)

Claim Number & Name of the adjuster on the claim, the adjuster email, and the phone number *

PIP or MedPay coverage? *

If so, how much? (PIP/MedPay Coverage)

UM/UIM coverage? *

If so, how much? (UM/UIM Coverage)

V. At Fault Party's Insurance Information

Name of Policy Holder (At Fault Party's)

Name of Driver

Driver’s Date of Birth

Driver’s License Number

Driver Contact Information

Year, Make, and Model of Their Vehicle

Insurance Company (At Fault Party's)

Policy Number (At Fault Party's)

Claim Number (At Fault Party's)

VII. Medical Treatment

(Please list all doctors including Ambulance and ER visits since the date of the accident)

Did you use an ambulance? *

Name of Ambulance Service *

Do you have copies of medical bills & records? *

If So please Upload copies of medical bills & records

Did you visit the emergency room? *

Name of ER *

Date of ER Visit

Do you have health insurance? *

Upload copy of insurance card.

Policy/Member #

Have you used it for this accident?

If So Where?

Group #

Do you have Medicare?

If yes, upload link (Medicare)

Do you have Medicaid?

If yes, upload link (Medicaid)

Do you have Tricare?

If yes, upload link (Tricare)

Please list all medical providers you have seen since the accident (include location, phone number, and account numbers)

Please list any medical providers you have seen before this accident (include year, location, phone number, and account numbers)