Personal Injury Client Intake Form

Client Intake Form

Please fill out the form below to submit your information to Proly, Laporte and Mulligan. Please only fill out this form out if we have requested this detailed information from you. For general inquiries and questions, fill out the Contact Us form.

Personal Information

First Name (required)

Middle Name

Last Name (required)

How did you hear about us? (required)

Street Address

City

State

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address (required)

Marital Status

Spouse's Name

Spouse's Age

Your Age

Your Date of Birth

Are you a Florida resident?
YesNo

If so, how long?

Children (Name & Ages)

Your Occupation

Employer Name

Employer Address

Dates of Employment

Salary (Gross)

Salary (Gross)

Have you lost income due to the accident?

If so, indicate date on which disability began and when you returned to work

Previous Employer

Are you a recipient of any type of government assistance program?

What benefits do you receive?

Driver's License State

DL Number

Social Security Number

Have you ever been convicted of any crimes?

Please list years, locations and charges for all convictions:

Accident Information

Date and time of accident:

Location of accident:

Investigating agency:

Did anyone receive a ticket?

Who was charged?

Charge:

Describe in detail how the accident happened:

Were you wearing a seatbelt?

If not, then why not?

Were you: Driver?

Were you : Passenger?

Other occupants: (names and relationship)

Vehicle involved: (Year, make & model)

Damage Amount: $

Location of damage:

Vehicle owner: (name & address)

Please list ALL vehicles owned by you at the time of the accident:

Please list ALL vehicles owned by any relatives who lived in your household at the time of the accident: (Include year, make & model, plus name of relative and their relationship to you)

Name & address of the driver who caused the accident:

Name and address of person who owns the vehicle which caused the accident:

Names and addresses of all other persons involved in the accident:

Do you know any witnesses to the accident? (Name, address and phone #)

Was the accident work-related?

Insurance Information

Your automobile insurer: Name?

Policy No:

Claim No:

Claims Adjuster (name):

Phone #:

Insurer on car in which you were riding (if a passenger):

Policy No:

Claim No:

Claims Adjuster (name):

Phone #:

Insurer on any cars owned by relatives residing with you at the time of the accident: Name?

Policy No:

Claim No:

Claims Adjuster (name):

Phone #:

Insurance companies for other vehicles involved in accident? For vehicle causing accident (name):

Policy No:

Claim No:

Claims Adjuster (name):

Has this insurance company contacted you?

Other insurance companies for other vehicles: (names)

Policy No:

Claim No:

Claims Adjuster (name):

Phone #:

Workers compensation insurance company. Name:

Do you carry any of the following?

A. Health Insurance

Insurer?

Policy or Group No:

B. Medicare:

Medicare #:

C. Medicare Supp.

Insurer?

Policy No:

D. Medicaid:

Medicaid #:

Have you given any recorded statements to anyone about the accident?

Who and when?

Injury and Medical Information

Were you injured in the accident?

Please describe with detail each part of your body injured, the nature of the injuries, and what if anything is bothering you now

Did you go to a hospital?

Where?

How did you get there?

When did you go?

When did symptoms first start?

How long were you there?

Provide the names and addresses of all doctors or chiropractors you or your relatives have seen for injuries related to this accident

Provide the names of any medical providers you or your family are scheduled to see for injuries relating to this accident, along with your appointment date

If you or your relatives have had any MRI's, EEG's or other diagnostic tests, please provide the name of the location performed and when

Past Medical History

Have you ever been injured before requiring medical care?

If so, please give the dates of all injuries:

The nature of the injuries:

How injured:

Whether job related:

Whether you were still under treatment at the time of this accident:

The names of all doctors or hospitals from which you received treatment, and the approximate dates of treatment:

Please list ALL doctors or hospitals from which you have received treatment for any reason in the past ten (10) years, along with the approximate dates of treatment and reason for treatment.

Who is your family doctor?

Comments or other information:

Please leave this field empty.