Personal Injury Intake Form

CLARK and FEENEY
THE TRAIN STATION, SUITE 106
1229 MAIN STREET
LEWISTON, IDAHO 83501

Personal Injury Questionnaire

NOTE: An Asterisk (*) Indicates REQUIRED Information.

* Name:

* Email:

Phone:

D.O.B.:

SSN#:

Date of Injury:

Location of Injury:

Name of Driver of Other Vehicle:

Address of Other Driver:

Telephone Number:

Name of Owner of Vehicle if Different than Driver:

Address of Owner of Vehicle:

Telephone Number:

 

Accident Information

In your own words, please briefly describe the accident/injury:

Please detail the damages to your vehicle if your case concerns an automobile accident:

Were pictures taken of the damage to your vehicle?

If pictures were taken, please make them available to our office.

 

Loss of Income

Are you claiming a loss of income as a result of this accident/injury?

If yes, please provide information as to the following:

Dates missed from work:

Wage per hour:

or Salary per month:

With regard to missed hours, did you:

Explanation if necessary:

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

 

Medical Information

Please list all medical providers you have seen as a result of this accident/injury below:

Medical Care Provider Address

 

Have you had surgery as a result of this injury/accident?

If so, at what facility?

Date of Surgery:

Please list the medical care providers you have seen previous to this accident/injury within the past ten (10) years below:

Medical Care Provider Address

 

What were your injuries from the accident?

What injuries still effect you (continuing symptoms)?

 

Changes in Lifestyle

Please describe in detail the activities you performed prior to the subject accident that you are no longer able to perform:

Please describe in detail how your injuries have changed your life:

With regard to missed hours, did you:

Explanation if necessary:

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

 

Insurance Information

YOUR automobile insurance information: OTHER PARTY insurance information:
Your Insurance Company:
Other Party Company:
Your Insurance Address:
Other Party Address:
Your Insurance City, State, Zip:
Other Party City, State, Zip:
Telephone Number:
Telephone Number:
Your Agent:
Other Party Agent:
Agent Address:
Other Party Agent Address:
Agent Telephone Number:
Agent Telephone Number:

 

Have any expenses been paid by either insurance company? If so, explain:

Do you have personal medical insurance:

If so, please provide:

Name of insurance company:

Address:

Policy #:

Have any expenses been paid by your personal medical insurance company? If so, explain:

Have you personally paid any expenses? If so, explain: