Client Intake Form – Personal Injury

Client Intake Form

Personal Injury Client Intake Form
Contact /Personal Information
Today's Date*
Name*
First Last
Date of Birth*
Month
Day
Year
Email*
Mobile Phone Number*
Home Phone Number
Address*
Street Address Address Line 2 City State ZIP Code
Preferred Contact Method
- Phone
- Email
- Text
- Any of the Above
Driver License Number
Insurance Information
Insurance Carrier*
Type of Insurance*
Auto? Homeowners? Motorcycle? Etc.
Group No.....
Case/Background Information
Cause of Injury*
If other, what caused your injury?
Date of Injury*

If the accident/injury occurred more than 3 years ago, you may not be able to proceed with a personal injury claim.
Are you at fault for the accident/injury?*
If the accident/injury you sustained was your fault, then this will be an impediment to recovery. However, if you were only partially at fault, you may still be entitled to compensation.
What City/County did the injury occur in?*
Where did the injury occur specifically?*
Name of streets, intersection, etc.
How did the injury/accident occur?*
Please briefly describe what/who caused the injury/accident
Extent of Injuries*
Please describe the injuries you have sustained
Have you been treated by a medical professional for your injuries?*
If Yes, please briefly describe the treatment you have received thus far
Additional Contact Person
Name*
First Last
Mobile Phone Number*
Email
Relationship to you
We Need Your Help!
How did you find us?
- Referral
- Google Search to website (willdefendwa.com)
- Avvo
- Yelp
- Thumbtack
- Bing
- Other

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Personal Injury Client Intake Form