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Ohio Birth Injury Attorney

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					                                              MILLS LAW OFFICE
                                              1-800- A LAWYER (252-9937)


623-F Park Meadow Road                    We are a Debt Relief Agency.                 61 North Sandusky Street
Westerville, Ohio 43081               We help people file for bankruptcy relief        Delaware, Ohio 43015
Telephone: (614) 523-3575                                                              Telephone: (740) 363-7761
Facsimile: (614) 794-7220
                                           under the Bankruptcy Code.                  Facsimile: (740) 363-0532

Westerville office located at                                                          Delaware office located in the
Schrock & Park Meadow                                                                  Chase Building, 2nd Floor

                                Initial Consultation Questionnaire - Personal Injury

 DATE: __________________________                  DATE OF COLLISION: ________________________

 REFERRED BY: __________________                   SOL (ATTORNEY WILL COMLETE):________

 _______________________________________________________________________________

 I.       PERSONAL INFORMATION:

          A.       YOUR NAME______________________________________________________

                   YOUR ADDRESS________________________________________________

                   CITY_________________________STATE______________ZIP_____________

                   HOME PHONE: (____) ______-________ WORK PHONE: (____) _____-_________

                   CELL PHONE: (____) ______-________ E-MAIL___________________________

                   DATE OF BIRTH: ____/___/___ SOCIAL SECURITY NO.:____________________

                   SPOUSE’S NAME: ____________________________________________________

                   SPOUSE’S DATE OF BIRTH: ____/____/___ DATE OF MARRIAGE: ___/___/__

                   SPOUSE’S SOCIAL SECURITY NO.: ___________________________________

                   CHILDREN (S) NAME (S) AND DATE (S) OF BIRTH: _____________________

                   _________________________________________________________________ _

                   PRIOR ATTORNEY REPRESENTATION, IF YES, WHO? ____________________

          B.       ALTERNATE CONTACT PERSON IN CASE WE CAN’T REACH YOU:

                   NAME: ___________________________________________________________



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            ADDRESS: ______________________________________________________

            TELEPHONE NO.: ________________________________________________
         ___________________________________________________________________

II.    EMPLOYMENT INFORMATION:

            EMPLOYER’S NAME/ ADDRESS (Parent (s)’ Employer if Client is a Minor)

            _____________________________________________________________

            _____________________________________________________________

            DID YOU MISS TIME FROM WORK? ______ FIRST DATE MISSED: ___/___/__
            DATE RETURNED TO WORK: ___/___/__ DID YOU LOSE ANY WAGES?_____
            YOUR RATE OF PAY: ____________________________________________

            EMPLOYER’S LIABILITY INSUTANCE CARRIER: ____________________


            SPOUSE’S EMPLOYER’S NAME/ ADDRESS:

            ________________________________________________________________

            __________________________________________________________

            DID SPOUSE MISS TIME FROM WORK? ______ FIRST DATE MISSED: ___/___/_
            DATE RETURNED TO WORK: ___/___/__ DID SPOUSE LOSE ANY WAGES?___
            SPOUSE’S RATE OF PAY: ___________________________________________

            EMPLOYER’S LIABILITY INSUTANCE CARRIER: _______________________
__________________________________________________________________________________

III.   YOUR AUTOMOBILE INSURANCE INFORMATION:

            NAME OF YOUR INSURANCE COMPANY: _________________________

            HAVE YOU FILED A CLAIM: ___________ DATE CLAIM FILED: ____/____/___

            ADJUSTER’S NAME: ________________________________________________

            ADJUSTER’S PHONE NUMBER: (____)_____-______ FAX #: (____)_____-___

            ADJUSTER’S ADDRESS: ___________________________________________

            CLAIM NUMBER: __________________________________________________
____________________________________________________________________________________


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IV.   YOUR HEALTH INSURANCE INFORMAITION: (Make copy of Card)

             NAME OF YOUR HEALTH INSURANCE: __________________________

             ADDRESS & PHONE NUMBER: (____) _____-_____

             POLICY NUMBER: _______________________________________________

__________________________________________________________________________________

V.    VEHICLE INFORMATION
      (Vehicle which you were driving or in which you were riding):

             YEAR AND MAKE OF CAR: ______________________________________

             OWNER OF VEHICLE: ___________________________________________

             OWNER’S ADDRESS: _____________________________________________

             OWNER’S TELEPHONE NO.: ____________________________________

             OWNER’S INSURANCE CO.: ______________________________________

             ADJUSTER’S NAME: ______________________________________________

             ADJUSTER’S PHONE NUMBER: ____________________________________

             ADJUSTER’S ADDRESS: _________________________________________

             CLAIM NUMBER: _________________________________________________

             DESCRIBE THE PROPERTY DAMAGE: ______________________________

            _______________________________________________________________
_______________________________________________________________________________

VI.   DEFENDANT INFORMATION:

      A.     NAME OF DEFENDANT (RESPOSIBLE PARTY): _____________________

             DEFENDANT’S ADDRESS:

             DEFENDANT’S PHONE NUMBER:

             DRIVER’S LICENSE # ____________________ LICENSE PLATE #

             OWNER OF AT FAULT VEHICLE



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            OWNER’S ADDRESS

            DEFENDANT’S INSURANCE CO.:

            ADDRESS OF INSURANCE CO.:

            ADJUSTER’S NAME:

            ADJUSTER’S PHONE NUMBER: ______________FAX NUMBER

            CLAIM NUMBER:
__________________________________________________________________________________


VII.   ACCIDENT INFORMATION:

           DATE OF INCIDENT: ____/____/____ STATUTE OF LIMITATIONS: ___/____/

           LOCATION OF ACCIDENT (INCLUDE COUNTY):



           NAMES AND ADDRESSES OF ALL PASSENGERS/DRIVERS IN CLIENT’S CAR:




           DESCRIPTION OF COLLISION:




           WAS A POLICE REPORT TAKEN? ________ WHICH POLICE DEPT?

          WERE PHOTOGRAPHS TAKEN AT SCENE?

          WITNESS(ES)’ NAMES AND ADDRESSES:




          AMBULANCE AND/OR TOW TRUCK DRIVERS AND ADDRESSES:




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            STATEMENTS OR CONVERSATIONS OF DEFENDANT WITH PLAINTIFF OR
            ANYONE ELSE AT SCENE?



            STATEMENTS OR CONVERSATIONS YOU MAY HAVE HAD WITH ANYONE AT
            SCENE:




VIII.   MEDICAL INFORMATION:

        FAMILY DOCTOR (S):

            ________________________ ________________________
            Name                     Address                    Telephone

            DID YOU GO TO AN EMERGENCY ROOM?

            IF SO, WHICH HOSPITAL?
                                  Name                             Address
            WERE X-RAYS TAKEN? _______________ IF SO, WHERE?



        OFFICES OR DOCTORES FROM WHOM YOU HAVE SOUGHT TREATMENT:

          __________________ _____________________________
          Provider Name      Address                       Telephone

          __________________ _____________________________
          Provider Name      Address                       Telephone

          __________________ _____________________________
          Provider Name      Address                       Telephone

          __________________ _____________________________
          Provider Name      Address                       Telephone

          __________________ _____________________________
          Provider Name      Address                       Telephone

          __________________ ____________________________
          Provider Name      Address                        Telephone



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__________________ ____________________________
Provider Name      Address                          Telephone



HOSPITALIZATION?

__________________   ____________________________
Name of Hospital     Address                        Date (s)

__________________   ____________________________
Name of Hospital     Address                        Date (s)




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Description: Ohio Birth Injury Attorney document sample