PERSONAL INJURY INFORMATION

Thank you for your confidence in selecting our law firm to protect your legal interests in your personal injury claim. In order to most effectively represent you, we are required to obtain the following information, some of which you might consider personal. So that you are comfortable providing this information, you should be aware that all information provided to this law firm is protected by the attorney-client privilege. We appreciate your effort in completing this form.

NOTICE: ALL INFORMATION BELOW IS SUBJECT TO KENNEDY LAW GROUP ATTORNEY-CLIENT AND WORK PRODUCT PRIVILEGE.

TODAY’S DATE:

Intake Coordinators Initials (Phone Intake operator's use only)

CLIENT INFORMATION

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

AIS ID:

entered by office

SOCIAL SECURITY #: (Last four digits are ok if uncomfortable, but may need full SS# if we take their case)

DATE OF BIRTH:

ACCIDENT INFORMATION

WHAT TYPE OF ACCIDENT WERE YOU INVOLVED IN?

DATE OF ACCIDENT:

TIME OF ACCIDENT:

LOCATION:

MOTOR VEHICLE ACCIDENT

DO YOU OWN A VEHICLE?

Yes

WHO IS THE OWNER OF THE VEHICLE YOU WERE DRIVING?

WERE YOU A DRIVER OR PASSENGER?

DRIVER

PASSENGER

WHAT ROAD WERE YOU TRAVELING ON?

WHAT WAS YOUR DIRECTION OF TRAVEL?

WHAT ROAD WAS THE OTHER DRIVER TRAVELING ON?

WHAT WAS THE OTHER DRIVER’S DIRECTION OF TRAVEL?

WHAT WAS THE NEAREST INTERSECTION TO THE ACCIDENT SCENE?

IN YOUR OPINION, WHAT CAUSED THE ACCIDENT?

ADMISSIONS MADE BY DEFENDANT:

WAS THE DEFENDANT DISTRACTED BY ANYTHING AT THE TIME OF ACCIDENT:

(i.e. talking on the phone, eating, drinking, etc.)

Yes

WERE ANY CITATIONS ISSUED?

Yes

DESCRIBE PROPERTY DAMAGE AND AMOUNT:

WERE PHOTOGRAPHS TAKEN?

Yes

BY WHOM? ATTACHMENT:

Add attachment

ATTACHMENT:

Add attachment

NUMBER OF KENNEDY LAW GROUP PHOTOGRAPHS? SUBJECT:

WAS YOUR VEHICLE EQUIPPED WITH AIRBAGS?

Yes

WERE YOU WEARING YOUR SEATBELT?

Yes

WAS YOUR SEATBELT OPERATIONAL?

Yes

INJURY INFORMATION

NECK PAIN:

Yes

UPPER BACK PAIN:

Yes

LOWER BACK PAIN:

Yes

Headaches - AT TEMPLES:

Yes

Headaches - AT BASE OF SKULL:

Yes

JAW SORENESS:

Yes

CLICKING OF THE JAW:

Yes

POPPING OF THE JAW:

Yes

DIZZINESS:

Yes

NERVOUSNESS:

Yes

SLEEP DISORDERS:

Yes

NOISE SENSITIVITY:

Yes

LIGHT SENSITIVITY:

Yes

WRIST SORENESS/WEAKNESS:

Yes

HAND SORENESS/WEAKNESS:

Yes

INJURY DESCRIPTION FROM AIS:

I.E. two heart attacks and other health problems

DESCRIBE OTHER INJURIES:

MEDICAL TREATMENT INFORMATION

FROM AIR (Accident/Incident report):

EMS?ER?

NAME OF AMBULANCE IF TRANSPORTED TO HOSPITAL:

NAME OF EMERGENCY ROOM/HOSPITAL:

DATES OF HOSPITALIZATION:

DOCTORS SEEN

FROM AIR (Accident/Incident report):

DOCTOR #1:

Yes

DOCTOR #2:

Yes

DOCTOR #3:

Yes

CLIENT MOTOR VEHICLE INSURANCE INFORMATION

NUMBER OF OPERABLE VEHICLES IN YOUR HOUSEHOLD:

YOUR AGENT AND/OR INSURANCE CARRIER:

ADDRESS:

TELEPHONE #:

ADJUSTER:

POLICY #:

CLAIM #:

TYPE OF INSURANCE

PERSONAL INJURY PROTECTION:

Yes

MEDICAL PAYMENT:

Yes

UNINSURED MOTORIST:

Yes

ADDITIONAL SOURCES OF CLIENT INSURANCE COVERAGE

SOURCE:

(i.e. Vehicle Owner, Address, Phone Number, Worker's Comp)

INSURANCE CARRIER:

ADDRESS:

TELEPHONE #:

ADJUSTER:

POLICY #:

CLAIM:

TYPE OF COVERAGE:

CLIENT HEALTH INSURANCE INFORMATION

DO YOU HAVE HEALTH INSURANCE?

Yes

YOUR INSURANCE CARRIER: ADDRESS: TELEPHONE #: ADJUSTER: POLICY NUMBER: GROUP NUMBER: COMPANY POLICYHOLDER WORKS FOR:

OTHER INSURANCE INFORMATION

DO YOU HAVE SSI/SSDI?

(SUPPLEMENTAL SOCIAL SECURITY DISABILITY INCOME)

Yes

DO YOU HAVE MEDICAID?

Yes

DO YOU HAVE STAYWELL?

Yes

DO YOU HAVE HEALTH EASE?

Yes

DO YOU HAVE WELLCARE?

Yes

DO YOU HAVE HEALTH CHOICE

Yes

DO YOU HAVE MEDICARE?

TYPE A

TYPE B

N/A

PASSENGER INFORMATION

PASSENGER #1:

Yes

NAME: ADDRESS: HOME PHONE: WORK PHONE: SOCIAL SECURITY #: DATE OF BIRTH: AGENT AND/OR INSURANCE CARRIER'S NAME: ADDRESS:

AGENT AND/OR INSURANCE CARRIER

PHONE:

AGENT AND/OR INSURANCE CARRIER

ADJUSTER: POLICY NUMBER: CLAIM NUMBER: RELATIONSHIP TO CLIENT: POSITION IN CAR:

PASSENGER #2:

Yes

NAME: ADDRESS: HOME PHONE: WORK PHONE: SOCIAL SECURITY #: DATE OF BIRTH: AGENT AND/OR INSURANCE CARRIER'S NAME: ADDRESS:

AGENT AND/OR INSURANCE CARRIER

PHONE:

AGENT AND/OR INSURANCE CARRIER

ADJUSTER: POLICY NUMBER: CLAIM NUMBER: RELATIONSHIP TO CLIENT: POSITION IN CAR:

RESIDENT RELATIVE INFORMATION

NAME:

RELATIONSHIP:

INSURANCE CARRIER:

ADDRESS:

TELEPHONE NUMBER:

ADJUSTER:

POLICY NUMBER:

CLAIM NUMBER:

Insurance - PERSONAL INJURY PROTECTION:

Yes

Insurance - MEDICAL PAYMENT:

Yes

Insurance - UNINSURED MOTORIST:

Yes

EMERGENCY CONTACT NOT RESIDING AT CLIENT’S ADDRESS

NAME:

RELATIONSHIP:

ADDRESS:

PHONE NUMBER:

DEFENDANT INSURANCE INFORMATION

(VEHICLE DRIVERS AND OWNERS)

DEFENDANT'S NAME:

ADDRESS:

TELEPHONE #:

INSURANCE COMPANY:

ADDRESS:

TELEPHONE #:

ADJUSTER:

POLICY #:

CLAIM #:

DEFENDANT’S VEHICLE MAKE:

MODEL:

YEAR:

VEHICLE OWNER?

Yes

ADDITIONAL DEFENDANT:

Yes

NAME: ADDRESS: PHONE: INSURANCE COMPANY: ADDRESS: PHONE #: ADJUSTER: POLICY #: CLAIM #: DEFENDANT’S VEHICLE MAKE: MODEL: YEAR: VEHICLE OWNER?

BACKGROUND INFORMATION

IF YOU HAVE ANY PRIOR INSURANCE CLAIMS, LAWSUITS, OR ACCIDENTS:

Yes

LOCATIONS: ATTORNEY'S NAME: TELEPHONE #: ADDRESS: AMOUNT OF SETTLEMENT (GROSS/NET): TYPE OF INJURY: TREATING HOSPITALS/DOCTORS: