ACCIDENT or INCIDENT CLIENT WORKSHEET

THANK YOU FOR YOUR CONSIDERATION OF OUR LEGAL SERVICES. FIRST, MAY WE REQUEST THE FOLLOWING INFORMATION. PLEASE TYPE IN ALL APPLICABLE BLANK AREAS AND CLICK SEND AT THE COMPLETION OF PAGE.

HOW DID YOU HEAR ABOUT US?

 

ARE YOU SUBMITTING THIS INFORMATION  ON YOUR OWN BEHALF 
OR FOR SOMEONE ELSE?   

WHAT TYPE OF ISSUE OR CLAIM CAN WE HELP YOU WITH? ("x" after category)

MARITIME ;  PERSONAL INJURY ;  DEATH ;  CIVIL RIGHTS  ;

OTHER [describe]

DATE INCIDENT [first] HAPPENED or DATE BY WHICH FUTURE 
ACTION TO BE TAKEN  Month Date Year

D E T A I L S OF ACCIDENT or  I N C I D E N T  C L A I M

Please Enter Your Responses ["Yes" or "No" or Requested Details] 
Following Each Applicable Question

FOR ACCIDENT CLAIMS :

1. What could have been done to help prevent the accident?

2. Did accident cause bodily injuries or death?  Yes or No

1. IF SO, specify what sort of injuries or cause of death

3. How soon was first health care treatment received?

1. IF SO, for what purpose or goal??

4. Is health care for injuries still being received?

FOR MOTOR VEHICLE & SMALL BOAT ACCIDENTS :

Which Vehicles/Vessels Had Liability Insurance at Time of Accident? 

[No insurance may make it impossible to help the prospective client]

* the above information is necessary for a response.