CONFIDENTIAL CLIENT INFORMATION SHEET Please fill in the form below. This information is imperative to get your case off to the right start. The more information you provide the better your results. This is all STRICTLY confidential. My Case Info SECTION ONEYOUR PERSONAL INFORMATIONName * First Last * Last Address * Street Address, City, State / Region, Postal / Zip Code Phone Email * Do you have a Facebook page? Yes No ***Please be careful of the social media post you make after your injury (dancing, sports, etc.)** Marital Status Single Married Seperated Divorced Widowed Spouse’s Name * First Last * Last Height Weight Right Handed or Left Handed? Right Handed Left Handed Dependents and Ages Driver’s License No. Driver’s License Expiration Date SECTION TWOOTHER PARTY’S PERSONAL AND AUTO INSURANCE INFORMATIONName of other party First Last * Last Do you have the other party’s insurance information? Yes No CHP has it Name of other party’s insurance Other party’s insurance policy number SECTION THREEYOUR AUTO INSURANCE INFORMATIONName of your insurance company Your Policy Number Your Auto Insurance Agent Phone Insurance Co. Address Do you have uninsured or underinsured motorist coverage? Yes No If yes, how much coverage do you have? SECTION FOURINFORMATION ABOUT THE ACCIDENTDate of Accident Time of Accident Where did the accident happen? Weather conditions? Where were you going? Where were you coming from? Please describe in detail the events that led up to the accident AND what occured during the accident: Taking any medications while driving? Yes No If yes, what kind of medications? Alcohol or drugs? Yes No SECTION FIVEWHAT HAPPENED AFTER THE ACCIDENTDid the person who hit you make any statements after the accident? If so, what did they say? Were there any witnesses that stopped and made statements? If so, provide their name, contact info and statement: Did the police or CHP assist in the accident? Yes No Any statements made by the officer concerning fault? Were you taken by ambulance? Yes No If yes, what was the name of the ambulance company? Trip number Did you take any pictures? Yes No ***If you have not taken any pictures you must immediately take pictures of all your injuries and damage to your vehicle and ASAP email them to our office. SECTION SIXINJURIESPlease describe your injuries caused by this accident: SECTION SEVENMEDICAL FACILITIES YOU HAVE BEEN TOPlease provide the name of the facility, city and phone number for any of the following that apply: SECTION EIGHT PRE-EXISTING INJURIES AND CONDITIONSPlease list any pre-existing injuries or conditions: Did this accident make those injuries worse? Yes No Not sure Prior Accidents Prior Accident Settlements SECTION NINEHEALTH INSURANCE INFORMATION Do you have HEALTH INSURANCE? Yes No Does Medicare pay any of your medical bills? Yes No Does MEDICAID pay any of your medical bills? Yes No Does Medi-Cal pay any of your medical bills? Yes No If yes, to receiving care from Medi-Cal, Medicaid or Medicare please provide your member number: **Please provide a copy of ALL Health Insurance Cards – including your Medicare/Medicaid/ or Medi-Cal card. SECTION 10INFORMATION ABOUT YOUR WORK Were you on the job at the time of the incident? Yes No Has this incident affected your ability to do your job? Yes No Employer Name Employer Address As a result of this accident, have you missed any days from work? If so, how many? SECTION ELEVENHOW HAS THIS INJURY AFFECTED YOUR DAY TO DAY LIFE? If you are human, leave this field blank. Submit
