Today’s Date:________________________
Dr. Referred to:____________________________
PERSONAL INJURY QUESTIONNAIRE PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS COMPLETELY. This information is extremely important in evaluating your case, determining the amount of your damages and preparing your case for eventual settlement or for trial. The information you give will remain confidential and will be used only to assist in the preparation of your case. FULL NAME: ________________________________________________________________________ ADDRESS:__________________________________________________________________________ CITY/STATE/ZIP:____________________________________________________________________ PHONE NUMBER: (Home) ________________________ (Cell) _________________________ DATE OF BIRTH: _________________ (Work) __________________________ (Alt #) ___________________________
SOCIAL SECURITY NO: _________________________
(Please note: for all questions that are multiple choice, you should circle the correct answer)
AGE: _______
MARITAL STATUS: Single Married Widowed Separated Divorced
IF MARRIED, FULL NAME OF SPOUSE _________________________________________________ HOW DID YOU HEAR ABOUT THE LAW OFFICE OF BENJAMIN SHEFTALL EICHHOLZ, P.C.? ____________________________________________________________________________________ WHERE DID YOU GET OUR TELEPHONE NUMBER? ____________________________________ DATE OF ACCIDENT: ________________________________________________________________ WHAT WAS YOUR POSITION IN THE CAR? Driver Front Passenger NO Rear Passenger
WERE YOU WEARING YOUR SEAT BELT AT THE TIME? YES
WHICH CAR WERE YOU IN (GIVE THE NUMBER FROM THE ACCIDENT REPORT AND DESCRIBE THE CAR) ________________________________________________________________ WHICH CAR WAS AT FAULT (NUMBER FROM THE ACCIDENT REPORT) _________________ WERE THERE ANY WITNESSES TO THIS ACCIDENT? YES NO NOT SURE
IF THERE WERE WITNESS, PLEASE GIVE THEIR NAME(S), PHONE NUMBER(S) AND ADDRESS(ES): 1. __________________________________________________________________________________ Name Address Phone Number 2. __________________________________________________________________________________ Name Address Phone Number
HAS ANYONE FROM ANY INSURANCE COMPANY CONTACTED YOU IN CONNECTION WITH THIS ACCIDENT? YES NO IF SO, GIVE THEIR NAME(S), PHONE NUMBER(S) AND/OR CLAIM NUMBER(S): ____________________________________________________________________________________ ____________________________________________________________________________________ HAS THE DAMAGE TO THE VEHICLE BEEN TAKEN CARE OF YET? YES NO
IF SO, WHAT WAS THE NAME OF THE INSURANCE COMPANY AND THE NAME OF THE ADJUSTER AND THE AMOUNT THE PROPERTY DAMAGE WAS SETTLED FOR?: ____________________________________________________________________________________ NAME & INSURANCE COMPANY OF THE PERSON WHO WAS AT FAULT IN THE ACCIDENT (This information can be found on the accident report): ____________________________________________________________________________________ Name of opposing party Insurance Company & Policy Number INSURANCE COMPANY OF THE VEHICLE YOU WERE IN: ____________________________________________________________________________________ Insurance Company of Vehicle Policy Number Address of the Insurance Company ____________________________________________________________________________________ Owner of Vehicle you were in Driver of Vehicle you were in DO YOU HAVE ANY OTHER TYPE OF INSURANCE COVERAGE? (i.e. Health, medicare, Medicaid, additional automobile insurance) YES NO IF YES, PLEASE LIST THE NAMES OF YOUR INSURANCE COMPANIES, POLICY NUMBERS, MEDICARE/MEDICAID NUMBERS & ADDRESSES, IF KNOWN: 1)__________________________________________________________________________________ Name of Your Insurance Company Type of Insurance Policy Number ____________________________________________________________________________________ Address and Phone Number of Your Insurance Company 2)__________________________________________________________________________________ Name of Your Insurance Company Type of Insurance Policy Number ___________________________________________________________________________________ Address and Phone Number of Your Insurance Company
DOES ANYONE ELSE IN YOUR HOUSEHOLD OWN AN AUTOMOBILE AND HAVE AUTOMOBILE INSURANCE? YES NO IF YES, PLEASE LIST THE NAME OF THEIR INSURANCE COMPANY, THE POLICY NUMBER, THE NAME THE POLICY IS IN AND THE ADDRESS OF THE COMPANY: 1. __________________________________________________________________________________ Name of the Policy Holder Relationship to You __________________________________________________________________________________ Name of the Insurance Company Policy Number Address 2. __________________________________________________________________________________ Name of the Policy Holder Relationship to You __________________________________________________________________________________ Name of the Insurance Company Policy Number Address LIST YOUR INJURIES:________________________________________________________________ ____________________________________________________________________________________ DID YOU GO TO THE HOSPITAL? YES NO
IF YES, WHICH HOSPITAL?___________________________________________________________ WERE X-RAYS TAKEN? YES NO AMBULANCE CAR
HOW WERE YOU TRANSPORTED?
IF BY AMBULANCE, WHICH ONE? ____________________________________________________ LIST ALL DOCTORS YOU HAVE SEEN IN RELATION TO THIS ACCIDENT: ________________ _________________________________________________________________________________ HAVE YOU RECEIVED ANY PRESCRIPTIONS? YES NO IF YES, SAVE ALL OF YOUR PRESCRIPTION RECEIPTS AND BRING THEM INTO THE OFFICE SO THAT THEY CAN BECOME A PART OF YOUR CLAIM. LIST ALL ILLNESSES OR ACCIDENTS THAT YOU HAVE SUSTAINED OR BEEN IN EITHER BEFORE OR AFTER THIS ACCIDENT: (NOTE: This includes automobile accidents, worker's compensation injuries, slip and fall accidents and/or any other kind of injury or chronic illness) ____________________________________________________________________________________ ____________________________________________________________________________________
WERE YOU EMPLOYED AT THE TIME OF THE ACCIDENT? IF SO WHERE:
YES
NO
____________________________________________________________________________________ Name of Company Address Phone Number DATE YOU BEGAN WORKING THERE: ________________________________________________ NUMBER OF HOURS WORKED DURING AN AVERAGE WEEK: ___________________________ HOW OFTEN ARE YOUR PAID: Weekly Semi-Monthly Monthly Hour Week Year
WHAT IS YOUR RATE OF PAY: $_____________ per (circle one)
WERE YOU RECEIVING THIS SAME RATE OF PAY FOR AT LEAST 13 WEEKS PRIOR TO YOUR ACCIDENT? YES NO IF NOT, PLEASE EXPLAIN:
NAME AND JOB TITLE OF YOUR IMMEDIATE SUPERVISOR:
YOUR JOB TITLE AND DESCRIPTION OF YOUR DUTIES AND RESPONSIBILITIES:
WERE YOU IN THE COURSE OF YOUR EMPLOYMENT AT THE TIME OF THIS ACCIDENT? (were you actually on the job at the time of accident?) YES NO HAVE YOU LOST ANY TIME FROM WORK BECAUSE OF THIS ACCIDENT? YES IF YES, PLEASE ANSWER THE NEXT FOUR QUESTIONS: 1. 2. 3. 4. DATE YOU FIRST MISSED TIME FROM WORK DUE TO THIS ACCIDENT:__________________________________________________________________ ARE YOU STILL OUT OF WORK? YES NO NO
HOW MANY DAYS DID YOU MISS FROM WORK AS A RESULT OF THIS ACCIDENT?
WERE YOU FIRED OR LAID OFF BECAUSE OF THE TIME THAT YOU HAVE MISSED/ARE MISSING FROM WORK DUE TO YOUR INJURIES RECEIVED IN THIS ACCIDENT? YES NO ____________________________________________________________________________________
MEDICAL HISTORY WHAT INJURIES DID YOU SUFFER FROM AS THE RESULT OF THIS ACCIDENT?
____________________________________________________________________________________ ____________________________________________________________________________________ PRESENT PHYSICAL CONDITION:_____________________________________________________ PRIOR PHYSICAL PROBLEMS: ________________________________________________________ ____________________________________________________________________________________ AT THIS TIME, PLEASE GIVE US ANY ADDITIONAL INFORMATION THAT YOU FEEL IS IMPORTANT TO YOUR CLAIM: ____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ REMEMBER, PLEASE ANSWER ALL OF THE ABOVE QUESTIONS. IF A QUESTION IS NOT APPLICABLE, PLEASE MARK IT "N/A". THANK YOU.
Revised August 28, 2007