Negligence Case Intake Form

DATE:

NAME:

ADDRESS:

HOME PHONE NO:

WORK PHONE NO:

EMAIL ADDRESS:

MARITAL STATUS::

OCCUPATION::

NAME AND ADDRESS OF EMPLOYER OR SCHOOL:

PRIOR MEDICAL HISTORY OR ACCIDENTS:

DATE OF ACCIDENT AND DAY OF WEEK:

PLACE:

WEATHER:

POLICE AGENCY WHO INVESTIGATED:

AMBULANCE?

DESCRIBE HOW ACCIDENT HAPPENED:

DESCRIBE INJURIES: (Hospitals, doctors, treatment)

DEFENDANT'S NAME AND ADDRESS:

DEFENDANT'S MOTOR VEHICLE: (Year, Make)

DEFENDANT'S INSURANCE COMPANY:

PLAINTIFF'S MOTOR VEHICLE: (Year, Make)

PLAINTIFF'S INSURANCE COMPANY:

NO-FAULT CARRIER:

IF PENNSYLVANIA - WAS FULL OR LIMITED TORT SELECTED?

PROPERTY DAMAGE:

PHOTOGRAPHS TAKEN?

LOCATION OF PHOTOGRAPHS:

WITNESSES:

HAVE YOU GIVEN A STATEMENT? TO: