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New Client Intake
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REQUEST A LIFE CARE PLAN
Attorneys: Please submit and we will contact you within 24-48 hours.
Download New Client Intake
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ATTORNEY INFORMATION
Law Firm
*
Attorney Name
Mr.
Ms.
Law Firm Contact Name (if not attorney)
*
First
Last
Title
Paralegal
Case Manager
Asst.
Other
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Email
*
Phone
*
Phone Type
Office
Cell
CLIENT INFORMATION
Name
*
First
Middle
Last
Client Sir Name
Mr.
Ms.
Language
English
Spanish
Other
Language Other
Phone
*
Email
*
DOB
*
MM
1
2
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5
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9
10
11
12
DD
1
2
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31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1999
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
SSN
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Client Type:
Driver
Passenger
Pedestrian
Cyclist
Other
Client Type Other
Was client employed at time of injury?
Yes
No
CASE INFORMATION
Incident Date
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Police Department
Police / Incident Report
Attached
N/A
File Upload
Click or drag files to this area to upload.
You can upload up to 5 files.
Police Report Number
Number of Claimants
*
Is this Workers' Compensation?
Yes
No
Accident
*
Rear-End
Sideswipe
Side-Impact
Head-on
T-Bone
Rollover
Slip & Fall/Bodily Injury
Other
Accident Other
Road Type
Highway
Intersection
Parking Lot
Street
Other
Road Type Other
Property Damage?
Total Loss
Repairable
Property Cost
Brief Description
*
Has client been involved in a prior accident(s)?
Yes
No
If yes, list incident date(s) and type(s) of injuries sustained in each
Does client have any pre-existing health conditions?
Yes
No
If yes, state the nature of client’s pre-existing conditions
Client Vehicle Year
Client Vehicle Make
Client Vehicle Model
Adverse Vehicle Year
Adverse Vehicle Make
Adverse Vehicle Model
ADVERSE/DEFENDANT INSURANCE INFORMATION
Liability Accepted?
*
Yes
No
Policy Limits
Policy/Claim #
Insured Full Name
*
First
Middle
Last
Insurance Company
Phone
CLIENT/PLAINTIFF INSURANCE INFORMATION
Type(s) of Coverage/Limits
*
UM
UIM
Med-Pay
PIP
Limits Available
Policy/Claim #
Insurance Company
Phone
Is client Medicare or Medicaid insured?
Yes
No
Did client carry private health insurance at the time of incident?
Yes
No
Is client Medicare or Medicaid eligible?
Yes
No
When do you anticipate this claim to settle?
0-2 Months
3-6 Months
7-9 Months
10-12 Months
1-2 Years
2+ Years
TREATMENT INFORMATION
Medical Bills to date (estimate)
*
Type of Treatment to date
Ambulance?
Yes
No
Description of Injuries
Hospital?
Yes
No
If yes, Hospital Name
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date of First Treatment?
Treatment requested
*
Physical Therapy
MRI/Imaging
Ortho-Extremity
Ortho-Spine
Pain Management
Neurology
Psychological Evaluation
Initial Medical Evaluation
Other
Other treatment requested
OTHER INFORMATION
Is there any additional information you would like to include that may be helpful?
SUBMIT
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Patients
Find a Personal Injury Attorney
Patient FAQ’s
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