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Plaintiff Information
If you don’t know some of these options, just say you don’t know.
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Plaintiff Information
Full Name
S.S. #
Full Address
Home Ph. #
Work Ph. #
Cell Ph. #
Email
Date of Birthday
MM slash DD slash YYYY
Is the client under 18 years old or requires legal representation?
No
Yes
Representative and/or Legal Guardian Information
Full Name
(Required)
Relationship to Plaintiff
(Required)
Address
(Required)
Phone #
(Required)
Email Address
(Required)
FAMILY(husband/wife):
Full Name
S.S #
Address
Phone #
Email Address
Does the accident in question produced a loss of service to this spouse?
No
Yes
CLOSE FAMILY/FRIEND (Emergency Contact):
Full Name
Address
Phone #
Email Address
EMPLOYMENT INFORMATION
Name
Address
Ocupation
Phone
Salary/Wage (per year) : $
Salary/Wage (per week) : $
On the books (get W2 form)
Yes
No
Lost time from work (due to the subject accident)
Yes
No
If yes, period of time absent:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Were you in a course of your employment at the time of the accident
Yes
No
STUDENT (school/college information)
Name
Address
Lost time from School (due to the subject accident)
Yes
No
If yes, period of time absent:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
PLAINTIFF/HOUSEHOLD INSURED MOTOR VEHICLES (other than the one involved in the subject accident):
Name of the owner
Relation to Plaintiff:
Motor vehicle information (model , registered state and plates #):
Name and claim # of the insurance company:
REFERRED BY:
TYPE OF CASE
PRIOR ACCIDENTS AND/OR PERSONAL INJURIES LAW SUITS (date and type of the injuries):
Name, address and phone # of prior attorney (if applicable):
PRIOR WORKERS COMPENSATION AND OR SOCIAL DISABILITY CLAIM:
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