Todays Date*
MM slash DD slash YYYY
Type of Case* Car Accident Drunk Driver Car Accident Hit and Run
What type of case is this?
First Name of Main Contact*
Your First Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
Middle Name of Main Contact
Middle Name
Last Name of Main Contact*
Last Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
Suffix of the Main Contact
For example, Jr., III, Esq.
Name of Friend who referred you to MattLaw
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Last
Name of Attorney who referred you to MattLaw*
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Last
Please tell us the name of the Attorney who referred you to MattLaw
My Relationship to Injured Person is that:* Your Contact Address*
This is the address where we will mail any documents relating to the case.
Main Contact's Cell Phone Number:
Main Contact's Phone Number:
Main Contact's Phone Number:
Main Contact's E-mail address: Main Contact's Facebook web address is:
What is your Facebook web address? Example https://Facebook.com/MattLaw
Main Contact's Social Security Number is:
Main Contact's Date of Birth is:* Enter the person's birth date
Main Contact's Gender is:* Male Female
Main Contact's Language:* English Spanish Only Spanish Mostly Spanish Some Vietnamese Only Vietnamese Mostly Vietnamese Some
Emergency or Alternative Contact if we can't find you
Please enter the name and any other information of who we can contact if for any reason we cannot contact you.
End of contact information for Main Contact, beginning of contact for other person who is injured or deceased First Name of the Injured Person*
Your First Name. This is where you enter the name of the Injured Person or deceased victim.
Middle Name of the Injured Person
Middle Name
Last Name of the Injured Person*
Last Name. This is where you enter the name of the Injured Person, child or deceased victim.
Suffix of the Injured Person
For example, Jr., III, Esq.
Address of the Injured person.*
Where does the injured person reside.
Gender of the Injured Person* Male Female
Injured person's Date of Birth:* My relationship to the Injured person is described here if they answered Other.
Social Security Number of the Injured Person
Notes about the injured person that we need to know.
If there is additional information about the injured person that did not fit in the boxes above, add that information here please.
End of Client Work History --- DATE OF LOSS This is the end of the Main Client Contact information, and if they are the Parent of an injured child, or the PR of a deceased person, or a Guardian of an incompetent, then we gather the injured person's basic information here.
Date of Incident/ Accident* Time of Incident / Accident Beginning of LIABILITY State where crash happened* Florida Alabama Arizona Arkansas California Colorado Delaware Georgia Hawaii Idaho Illinois Indiana Kansas Louisiana Maryland Massachusetts Michigan Minnesota Missisippi 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
Select the State where the Crash happened
County where incident happened* ALACHUA BAKER BAY BRADFORD BREVARD BROWARD CALHOUN CHARLOTTE CITRUS CLAY COLLIER COLUMBIA DADE DE SOTO DIXIE DUVAL ESCAMBIA FLAGLER FRANKLIN GADSDEN GILCHRIST GLADES GULF HAMILTON HARDEE HENDRY HERNANDO HIGHLANDS HILLSBOROUGH HOLMES INDIAN RIVER JACKSON JEFFERSON LAFAYETTE LAKE LEE LEON LEVY LIBERTY MADISON MANATEE MARION MARTIN MONROE NASSAU OKALOOSA OKEECHOBEE ORANGE OSCELOA PALM BEACH PASCO PINELLAS POLK PUTNAM ST. JOHNS ST. LUCIE SANTA ROSA SARASOTA SEMINOLE SUMTER SUWANNEE TAYLOR UNION VOLUSIA WAKULLA WALTON WASHINGTON
Select the County where the accident happened
Location of the accident*
Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
Where were you sitting in the car at the time of the collision?* Where was the injured person sitting in the car?* Who owned the vehicle you were in at the time of the collision?* Who owned the vehicle the injured person was in at the time of the collision?* Name of the person who owned the car the injured person was in at the time of the collision
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The name of the company that owned the vehicle that the injured person was in is:*
Do you have the address of the owner of the vehicle the injured person was in at the time of the crash? Yes, I know the address of the owner of the vehicle the injured person was in. No, I don't have the address of the owner of the vehicle.
Address of the vehicle owner that the Injured person was riding in at the time of the collision
Were you wearing your seat belt at the time of the collision?* Was the Injured Person wearing their seat belt at the time of the collision?* How many vehicles were involved in the collision?* Did you know a collision was going to happen before it did? Was the Injured Person aware that collision was going to happen before it did? What was seen or heard before the collision happend?
Describe what you saw before the impact.
What evasive action if anything was taken by anyone to avoid the crash?
Did an airbag deploy in your car?* Did an airbag deploy in the Injured Person's car?* Was the car that you were in working well at the time of the crash?* Did your car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Was the car that the Injured Person was in, was it working well at the time of the crash?* Did the car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Describe the mechanical problems with the car.*
Describe what was wrong with the vehicle that may have had something to do with the collision.
Weather Conditions were? Road Conditions Was alcohol or drug use any part of this accident?* Was anyone intoxicated during the accident?
What role did alcohol or drugs have in this accident*
Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Were you partially at fault for this accident? Do you believe the Injured Person was partially at fault for this accident? What did you do wrong that may have contributed to the accident?*
What did the Injured Person do wrong that may have contributed to the accident?*
Where was the first point of impact on your vehicle Right before the impact was your vehicle: How many seconds were you at a full stop before being hit from behind?* Where was the first point of impact on the at fault vehicle Describe what happened that caused the accident.*
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the At Fault Driver, Person or Company do that makes you feel they were at fault?*
What specifically did the at fault person do? Why are they negligent?
After the impact between the vehicles, how far apart were they before anyone moved them from the crash. After the initial collision the vehicles were stuck together and did not come apart. After the collision the vehicles separated and ended up a few feet apart from each other. After the collision, the vehicles separated and ended up over one car length apart from each other.
Did you hear the at fault person say anything about the crash?* No, after the crash I never heard the at fault person say anything. Yes, after the collision I heard the at fault person talking.
We want to know what admissions they may have made where they admitted fault in some way.
The At Fault driver made these statements or admissions to: Who were the admissions made to?
The at fault person said the following*
Admissions like, I did not see you. It is all my fault. I missed my turn. I don't know what happened. My brakes have been bad for a while.
Witness Identification who may be a witness? How many people besides yourself were in your vehicle?* No one else, I was alone in my car. 1 other person was in my car with me. 2 other people were in my car with me. 3 other people were in my car with me. 4 other people or more were in my car with me.
How many passengers besides the Injured person were in the Injured Persons vehicle?* No one else, the Injured Person was alone. 1 other person was in the car with the Injured Person. 2 other people were in the car with the Injured Person. 3 other people were in the car with the Injured Person. 4 other people or more were in the car with the Injured Person.
The name of the First other person in the vehicle*
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Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the First Other person in the Vehicle?* What is the Address of the First Other Person in the Vehicle
I believe the First Other Person in the vehicle* The name of the Second other person in the vehicle*
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Last
Do you have the address of the Second Other person in the Vehicle?* What is the Address of the Second Other Person in the Vehicle
I believe the Second Other Person in the vehicle* The name of the Third other person in the vehicle*
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Last
Do you have the address of the Third Other person in the Vehicle?* What is the Address of the Third Other Person in the Vehicle
I believe the Third Other Person in my vehicle* The name of the Fourth other person in your vehicle*
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Do you have the address of the Fourth Other person in the Vehicle?* What is the Address of the Fourth Other Person in the Vehicle
I believe the Fourth Other Person in my vehicle* How many Eye Witnesses are you aware of?* None, I know of no eye witnesses. One, I know of one eye witness. Two, I know of two or more eye witnesses
Name of Eye Witness 1*
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What is the name of the first eye witness who you have not told us about already?
Name of Eye Witness 2*
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Last
What is the name of the first eye witness who you have not told us about already?
How do we get in touch with any eye witness? Phone number, address, anything to help us find and talk with them.*
How can we get in touch with any eye witnesses so we can ask them what they remember about this.
End of ID of people in Clients car / Beginning of description of the Incident Color, make and year of the at fault car
How many people were in the at Fault vehicle?* Just the driver who was alone The at fault driver and 1 other person The at fault driver and 2 other persons The at fault driver and 3 other persons The at fault driver and 4 other persons
Did the police come to the scene of the crash?* Law Enforcement that came to the crash were* Which City Police Department?*
What is the Police Report Case Number?
Did anyone get a Traffic Ticket or was there any arrests?* Do you know what the other driver was ticked for?* No, I have no idea what ticket the other driver got. Yes, I know what the other driver's ticket was for.
What was the other drivers ticket for?*
Enter what their ticket was for. For example, following too closely
What were you ticketed for?*
If you got a traffic citation, what was it for?
Status of any Traffic Court or Criminal Court Dates* Were there any Skid Marks our gouges left in the road?* Describe the Skid Marks or Gouges.
Which vehicles left skid marks, which vehicles left gouges in the road, how long were they, where were they located?
EVIDENCE Section: Photographs Check all that you have or have access to* Evidence
Do you want us to hire a photographer to take photos of anything? Where is the Car to be photographed?*
Who else may have any photographs or evidence to help prove your case?
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
What other evidence might exist that we should try to obtain to help prove your case? Who has it, what is it, how do we get it?
Tell us about anything else we might want to photograph, or obtain to help prove your case?
End of Evidence and photographs. Beginning of Injuries Did Fire Rescue come to the accident scene? Which Fire Rescue Department came to the scene of the crash?*
Tell us the name of the Fire Rescue department so we can order the records.
Did you ever go to a hospital as a result of this car crash?* What is the name and location of the Hospital you went to?*
How did you get to the hospital? Who drove you to the hospital?
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What was the date that you went to the hospital? Were you admitted to the hospital over night* What Date were you discharged from the hospital If they were admitted to the hospital, when did they get discharged? If they are still in the hospital, put a date in that they expect to go home.
Check the boxes for all injuries you received from this crash* Describe any and all injuries you relate to this car crash*
What other injuries or physical or psychological problems are you having that you relate to this crash that you have not checked above.
What doctors or health care people have you seen since the crash?*
Please tell us all the doctors, chiropractors, X-ray, MRI facilities that you have been to after this crash. Name, city, location, so that we can order all of your medical records. If you have not seen anyone yet, just type in NONE.
Have you been prescribed any medications?* Injuries
What medications have you been prescribed because of this incident*
Please list the medications that you have been prescribed, the name of the medication, the strength of the medication and where you got the prescription filed.
Example: Flexeril, 80mg as needed, filed at CVS pharmacy on Waters Avenue in Tampa. Or, None, if you don't have any prescriptions.
Have you been prescribed medications but have not yet filled the prescription? Why?* Did you know that Pre-Existing Injuries or conditions can make your case worth more money, not less?* What medications were you taking on a regular basis before this incident?*
Were you taking any medications on a regular basis, such as for a heart condition, or arthritis, blood pressure, diabetes, anything at all. If none, just type in NONE.
Check the boxes for Prior Injuries you have sought treatment for BEFORE this incident* Describe your prior treatment, Who, What When and Where*
We may want to order these records so that we can make sure your treating doctors know about your prior conditions so they can factor them into your health care plan.
List all hospitals you have been in over the past 10 years*
Please tell us each and every hospital you have been seen in over the past 10 years. Including short visits like an Emergency room and released, to long term admission as a patient.
Prior Claims where you sought money from an accident?* Have you ever made any sort of claim before this one? Like workers compensation, car accident, slip and fall, dog bite, class action claim where you were a party?
Tell us about all of your prior claims.*
We need to know about any and all claims you may have had so we can get those records and let your doctors know about your prior injuries and claims.
Prior Chiropractic Care* Have you ever seen a chiropractor, even for one visit before this incident?
What Chiropractors have you seen and what address can we request your records?*
We need the name, address and approximate date that you saw chiropractors before this accident. Also, it may be a good idea for you to return to them to be seen as a Before and After Doctor to help prove your case.
Have you ever had prior psychiatric or psychological care or counseling?* Have you ever seen a psychiatrist, psychologist, or been baker acted before this incident?
What psychiatrists or psychologists have you seen and what address can we request your records?*
We need the name, address and approximate date that you saw any mental health professionals before this accident.
Have you ever had a Workers Compensation Claim?* Tell us about your Workers Compensation Claim(s)*
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Has any doctor taken you off of work because of your injuries in this car crash? Have you been given a work disability slip from anyone because of your injuries from this car crash?
How much work have you missed, or will you miss?
Help us figure out how much work you will miss because of your injuries from this incident. You can say in hours, days, weeks or years.
Which doctor specifically wrote a work restriction for you?
Please give us the name and location of the doctor that has taken you off of work. We need to order your records
What is your best estimate of how much money you will lose (going forward only) as a result of your work restrictions.
What is your estimated Lost wages (in the past only) so far?
Please calculate as best you can what amount of money you have lost so far as a result of this crash?
Beginning of Clients UM and Other Insurance coverage What Insurance Coverages do you have on your own Personal Policy?* What Insurance Coverages did the Injured Person have on thier own car insurance policy?* What is the name of your/injured person's car insurance company that was in effect on the date of this accident?*
What is your/injured person's insurance Policy Number?
Are all of the car insurance policies "Florida" Policies?* Yes, all of my insurance policies are from Florida. No, all of my car insurance polices are from another state other than Florida. No, some of my car insurance policies are from another state other than Florida.
Are any of your policies from out of the State of Florida? We need to know this so that if you have an out of state policy, the coverage's may be different that typically required by Florida Law.
Which State is your Insurance Policy written for?* 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 Armed Forces Americas Armed Forces Europe Armed Forces Pacific
If you don't have a Florida insurance policy, which state is the policy from?
Which of your out of State Insurance policies are Not Florida policies?* What are the Med Pay Policy Limits?
If you know the Med Pay policy limits please indicate this, if you don't know, put Unknown
What are the UM Limits?
What are the limits on your UM policy? If you don't know or are not sure, just put unknown.
Are the UM coverages STACKED UM?* Stacked UM coverage gives you more benefits. Also, they can be stacked even if they are with different insurance companies, and sometimes even on some motorcycle policies.
How many vehicles do you own, Cars, trucks, motorcycles* What is the total number of motor vehicles that you own that may provide UM coverage to you?
How many vehicles did the Injured Person own, Cars, trucks, motorcycles at the time of this accident?* What is the total number of motor vehicles that the Injured Person owned on the day of the crash that might provide UM coverage to them?
What other Insurance Companies might have any car insurance coverages with?* Do you happen to have different insurance companies for different vehicles? If so, we want to contact them all and find out if there are any other UM policies to cover your losses.
My Umbrella Insurance Company is:*
The Umbrella Insurance Policy Number is:
Provide your Umbrella Policy Number if known, if you don't know, enter Unknown
Does the Umbreall Policy offer UM Coverage?* Is the UM Umbrella STACKED?* If you have Stacked UM Umbrella Insurance please let us know.
What other Insurance Companies do you possibly have coverage with?*
What other Insurance Companies could the Injured Person possibly have coverage with?*
Who is your Insurance Agent so we can ask about your Insurance Policies
Please give us the name and phone number of your Insurance Agent so we can see what other coverage's you might have to protect you and your family.
Who is the Injured Person's Insurance Agent so we can ask about additional Insurance Policies?
Please give us the name and phone number of the Injured Person's Insurance Agent so we can see what other coverage's might be available to protect them.
End of UM and Other Insurance coverage PIP Questions for Main Client At the time of the crash did you own any 4 wheeled vehicles? Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage.
Was the Car or other 4 wheeled vehicle you owned at the time of the crash Insured?* Your PIP Insurance will pay your medical bill and wage benefits Because you owned a car and it was insured, you use your own PIP insurance. This is why it is called "No Fault" insurance.
On the date of your crash was your vehicle capable of being operated on the roads of Florida?* If their answer is YES, they are out of luck, no PIP. If their answer is No, the get PIP from their resident relative or the vehicle they were occupying.
You probably have No PIP insurance to pay your medical bills or lost wages. If you owned a car that was being operated on Florida roads and did not have insurance on that car, then most likely your health insurance or disability insurance will have to pay your medical bills and lost income, unless we recover them from the at fault person.
At the time of the crash did you live with any relative?* Did you live with any relatives at the time of the crash? If you did and your relative had car insurance then you may be covered under their PIP policy. Resident relative includes parents, spouse, child, brother, sister, grandparent. If you did live with any resident relatives, then you get Pro-rata PIP insurance from the various resident relative policies in your household.
How many relatives did you reside with that had their own car insurance policies?* 1 resident relative 2 resident relatives 3 resident relatives
Your Relatives PIP Insurance will pay your medical bill and wage benefits. Because your car was either inoperable, or out of state, and you lived with a resident relative, you get your relative's PIP insurance.
What is the name of the First relative that you lived with at the time of the crash that has their own car insurance policy?*
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If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
Name of your First Resident Relative's Insurance Company*
What is the name of the Second relative that you lived with at the time of the crash that has their own car insurance policy?*
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If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
Name of your Second Resident Relative's Insurance Company*
What is the name of the Third relative that you lived with at the time of the crash that has their own car insurance policy?*
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If you don't have car insurance, but you live with a relative who owns a car and has insurance, then you get PIP benefits from them.
Name of your Third Resident Relative's Insurance Company*
Did the owner of the vehicle you were in at the time of the crash have Car Insurance?* You get PIP insurance from the owner of the car you were in at the time of the crash. Because you did not own a car, and did not live with a resident relative, you get the PIP insurance from the car you were in.
Beginning of PIP Questions for the Injured Person At the time of the crash did the Injured Person own any car or any 4 wheel vehicles? Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage for this car accident.
Was the Injured Person the owner of the vehicle they were in at the time of the crash?* Was the Car or other 4 wheeled vehicle that was owned by the Injured Person, Insured?* The Injured Person's PIP Insurance will pay their medical bill and wage benefits. Because the Injured Person owned a car and it was insured, they use their own PIP insurance. This is why it is called "No Fault" insurance.
On the date of the crash was the Injured Person's vehicle capable of being operated on the roads of Florida?* If their answer is YES, they are out of luck, no PIP. If their answer is No, the get PIP from their resident relative or the vehicle they were occupying.
The Injured Person's has no PIP Insurance to pay their medical bill and wage benefits. Because the Injured Person owned a car and it was not insured, and it should have been insured they have no insurance to pay their medical bills or lost wages unless we collect them from the at fault party.
At the time of the crash did the Injured Person live with any relative?* Did the Injured Person live with any relatives at the time of the crash? If they did and their relative(s) had car insurance then they may be covered under their relative's PIP policy. Resident relative includes parents, spouse, child, brother, sister, grandparent. If they did live with a resident relative(s), then they get Pro-rata PIP insurance from the various resident relative policies in their household.
The Injured Person's Relative's PIP Insurance will pay their medical bill and wage benefits. Because the Injured Person's car was either inoperable, or out of state, and they lived with a resident relative, they get their relative's PIP insurance.
How many relatives did the Injured Person reside with that had car insurance policies?* 1 resident relative 2 resident relatives 3 resident relatives
What is the name of the First relative the Injured Person lived with at the time of the crash who had their own car insurance policy?*
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Last
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
Name of the Injured Party's First Resident Relative's Insurance Company*
What is the name of the Second relative the Injured Person lived with at the time of the crash who had their own car insurance policy?*
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Last
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
Name of the Injured Party's Second Resident Relative's Insurance Company*
What is the name of the Third relative the Injured Person lived with at the time of the crash who had their own car insurance policy?*
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Last
If the Injured Person did not have car insurance, but they lived with a relative who owns a car and has insurance, then they get PIP benefits from their relative's insurance company.
Name of the Injured Party's Third Resident Relative's Insurance Company*
Did the owner of the vehicle the Injured Person was in at the time of the crash have Car Insurance?* The Injured Person get PIP insurance from the owner of the car they were in at the time of the crash. Because the Injured Person did not own a car, and did not live with a resident relative, they get the PIP insurance from the car they were in.
What is your insurance Company Adjuster's Name?
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What is your insurance companie's Phone number?
What is your Policy Number?*
What is your Claim Number?*
Enter the claim number or if you don't have one enter Unknown.
Who was the titled owner of the car that you were in at the time of the crash?* Who owned the vehicle that you were in when the collision occurred?*
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Which Rental Car Company owned the vehicle you were in*
We need the name of the rental company so that we can find out what insurance was taken out that may protect you.
Who rented the car that you were in at the time of the crash?*
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Were you covered under any Rental Car Insurance at the time of the crash?* If you were in a rented car, did the renter of the car take out any insurance coverage through the rental car company, or credit card?
Were you the "Named" Insured under that car insurance policy?* Yes. My name is on the insurance policy. No. I am not named in the insurance policy, it is someone else policy.
Matt, look at other questions that may go with this question.
Who is the "Named" Insured under the policy?*
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End of PIP beginning of At Fault Insurance This is where we start recording that At Fault Insurance Company information.
Which Insurance Companies have contacted you so far?* First Name of At Fault Driver*
First Name of the At Fault Driver.
Middle Name of At Fault Driver
Middle Name
Last Name of At Fault Driver*
Last Name of the At Fault Driver.
Suffix of the At Fault Driver
For example, Jr., III, Esq.
Address of the At Fault Driver
Date of Birth of the At Fault Driver At Fault Drivers Licnese Number
Who is the At Fault Driver's Insurance Company
Name of the At Fault Insurance Company
What is the At Fault Driver's Insurance Company Claim Number
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Name of the At Fault Insurance Company Adjuster
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Last
Phone number for the At Fault Insurance Company or adjuster
The owner of the vheicle that was at fault is:* Salutation for Owner of the At Fault Vehicle Mr. Mrs. Ms. Dr.
First Name of the Owner of the At Fault Vehicle
First Name of the At Fault vehicle OWNER. If the owner is a company, just enter the name of the company that owned the vehicle that caused injuries.
Middle Name of the Owner of the At Fault Vehicle
Middle Name
Last Name of the Owner of the At Fault Vehicle
Last Name of the At Fault Driver.
Suffix of the Owner of the At Fault Vehicle
For example, Jr., III, Esq.
Address of Owner of the At Fault Vehicle
Owner's Insurance Company Name
Name of the Insurance Company for the Owner of the vehicle that was at fault.
Owner's Insurance Company Claim Number
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Owner of the Vehicle's Fault Insurance Company Adjuster
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Phone number for the vehicle Owner's Insurance Company or adjuster
Do you believe the at fault driver was working or running an errand for someone else? What is the name of the drivers Employer?
Who was the driver working for when he caused the crash? We will sue his employer also.
What makes you think they were working at the time of the accident?*
Explain why you think the bad driver was working or running an errand for someone else when the crash occurred? We want to know to seek additional insurance coverages for you.
Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information Health Insurance Yes or No* Do you have any type of Health Insurance?
Name of your Health Insurance Company
What is your Health Insurance Policy Number
Has Health Insurance paid any of your bills?* Effective Date of your Health Insurance This date is on your health insurance card and it tell us when your coverage first began.
Heatlh Insurance Information, What is the contact information for your Health Insurance*
Medicare Yes or No* Do you have any type of Medicare Insurance or supplements? Medicare is generally for people over the age of 65, or if the person is on Social Security Disability.
What parts of Medicare do you have, check all that apply* Name of your Medicare Insurance Company for Part A*
What is the name of Part A
What is your Medicare Part A Policy Number
We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part A paid any of the bills related to this incident?* We need to know if medicare part A has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part A Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part B*
What is the name of Part B Medicare Insurance Company
What is your Medicare Part B Policy Number
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part B paid any of the bills related to this incident?* We need to know if medicare part B has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part B Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part C*
What is the name of Part C Medicare Insurance Company
What is your Medicare Part C Policy Number
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part C paid any of the bills related to this incident?* We need to know if medicare part C has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part C Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part D*
What is the name of Part D Medicare Insurance Company
What is your Medicare Part D Policy Number
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part D paid any of the bills related to this incident?* We need to know if medicare part D has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part D Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Medicare Information, What is the contact information for your Medicare*
Do you (injured person) have Medicaid? Yes or No* Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
Name of your Medicaid Insurance Company*
What is your Medicaid Policy Number
We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
Effective Date of your Medicaid Insurance This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Medicaid paid any of the bills related to this incident?* We need to know if Medicaid has paid any money to help with your care as a result of this incident?
Medicaid is only available to poor people, not related to age.
Do you (injured person) have Wellcare? Yes or No* Wellcare is available to children and adults of low income, and may not have Medicare Parts A, B or C. We need to know what bills if any Wellcare has paid.
Name of your Wellcare Insurance Company*
It might be called just Wellcare, and it may be managed by another company. We need the company name.
What is your Wellcare Policy Number
Effective Date of your Wellcare This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Wellcare paid any of the bills related to this incident?* We need to know if Wellcare has paid any money to help with your care as a result of this incident?
Wellcare is only available to poor people, not related to age.
Medicaid contact information*
What is their address or contact information for Medicaid?
Do you have any sort of Disability Insurance* If you have any disability insurance that may pay you benefits please let us know about them.
Name of your Disability Insurance Company*
Has your Disability Insurance made any payments to you* Did you receive any payments for short term or long term disability? If so, we need to contact your disability insurance companies to know what their lien is.
Notes regarding Insurance-Medicare-Medicade or any other Collateral Source
Any notes about any sort of collateral source, which is some other company paying any sort of related bills for lost wages or medical treatments. AFLAC would be included here as well. Get copies of any insurance cards
End of Health Insurance Beginning of Property Damage MVA Is there a claim for Property Damage to your vehicle?* What Year is your vehicle
What kind of vehicle do you have
What kind of car was damaged in this crash?
What color is your vehicle
What color is your car
Can your car be fixed or do you think it is a total loss? Was your vehicle towed from the scene? Where is your car now? Is it still accruing storage charges?
Is your car or bike still accruing storage charges?
End of Property Damage MVA Recorded Statements: Have you given anyone a Recorded Statement? Who did you give a Recorded Statement to?*
We want copies of any recorded statement you may have made, or any court appearance you have made. Please tell us when you gave the recording and to whom?
Beginning of Client Assessment and lifestyle Marital Status* Single Married Divorced Widowed Separated and not divorced
Name of Spouse, Ex, or Partner*
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How many Children do you have? Have you filed your income tax returns in the past? What are the circumstances of your not filing taxes?
Why have you not filed your taxes? Maybe you were paid cash? Maybe you did not make enough, maybe you did not know how to file. What ever the reason, please let us know.
Do you have copies of your income tax returns? What is the name of the person or company that prepared your tax returns?
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What is the highest level of education that you have achieved Some High School GED High School diploma Some college AA or AS degree Bachelors Degree Masters Degree Doctorate Degree Medical Degree
Have you ever been in the military? Were you honorably discharged from the military?* Have you ever had your drivers license suspended or revoked?* Have you ever been arrested?* Why, when and what were you arrested for?*
Please tell us about any and all arrests
Have you ever been convicted of a felony* How many Felony Convictions, what year, what state and county*
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Have you ever been convicted of a Misdemeanor involving theft, false statments or dishonesty shop lifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
How many Misdemeanor Convictions, what year, what state and county*
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Are you thinking about filing for Bankruptcy now or in the future? Filing Bankruptcy may mess up your injury case, but if we know about your filing for bankruptcy before you file, it will help you recover the money, rather than your creditors.
Have you ever hired a lawyer before this claim? Have you consulted with other attorneys about this case? No, MattLaw is the first attorney I have consulted with Yes, I have spoken to other lawyers but not hired them Yes, I am currently represented by another attorney Yes, I have hired other attorneys but they are not my attorney now
We would like to know if you have sought legal representation before calling us?
If you have an attorney already, why are you calling us? The reason I am seeking a second opinion or unhappy with my lawyers is: Are you firing your attorney for good Cause? If you have a good reason to fire your attorney that has an effect on their ability to recover fees for the work they did.
What is the name of your attorney you have now that you want to fire
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Address of your attorney you want to fire
We can send him a letter on your behalf terminating him, but we need his address to obtain a copy of your file and send him a letter discharging him from your case.
Before hiring your attorney you have now who you are considering firing, how many other attorneys have you hired for this claim? None other, that the one I have now 1 attoreny before the one I have now 2 attorneys before the one I have now 3 or more attorneys before the one I have now
We need to collect all of your records and often times the first or second attorney has some investigative records that we might need to help prove your case.
What is the name of the first attorney you hired before the one you are about to fire?
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What is the address of the first attorney you hired
What is the name of the Second attorney you hired before the one you are about to fire?
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What is the address of the second attorney you hired
What is the name of the Third attorney you hired before the one you are about to fire?
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What is the address of the Third attorney you hired
Do you have any other Pending Injury Claims that are going now? Are you bringing any other personal injury claims other than this one?
My other claim is: A previous car accident A slip and fall or trip and fall claim A medical malpractice case A pharmancy mistake claim A bicycle accident claim A pedestrian claim A motorcycle claim A trucking accident claim A products liabilty claim A negligent security claim Some other type of claim
Do you have any other pending pclaims going on now?"
What is the name of your attorney handling the other pending claim?
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What is the address of the attorney handling your other pending claim?
Prior Lawyers Names, Address and reasons you hired them.
Please let us know the names, addresses and types of prior injury claim attorneys, workers compensation attorneys or any other notes that may help us with your case. What is the status of their representation of you now?
Is there anything else you think we should know about you or your claim that has not been covered above?
Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.
