New Client Information

Attorney-Client Privileged & Confidential

PLEASE UNDERSTAND THAT NO ATTORNEY-CLIENT RELATIONSHIP IS CREATED BY THIS FORM. PURSUANT TO VIRGINIA STATE BAR GUIDELINES, SUCH A RELATIONSHIP IS CREATED ONLY BY EXECUTING A WRITTEN REPRESENTATION AGREEMENT

Today's Date:

CLIENT INFORMATION

Full Name:

Date of Birth:

SSN:

Present Home address::

Home Phone #:

Work Phone #:

Cell Phone #:

Email Address:

Marital Status:

Name of Spouse?

Name of nearest relative not living with you:

Relation

Address:

Phone:

Referral Source:

ACCIDENT INFORMATION

Date of Accident:

Statute Runs

Street Location:

City:

State:

Description of Events:

Photos Taken?

Statement Given?

To Whom?

Was a Police Report Field?

Officer's Name:

Was the defendant charged?

If so, with what charge?

Witnesses

Name: Address: Phone:

MEDICAL INFORMATION

What injuries did you suffer in this accident?:

Were you taken to the hospital by ambulance?

Which emergency room did you go to?

Who is your primary care physician?

Where have you treated?

DEFENDANT INFORMATION

Name:

Address:

Corporate Employer?

Name: Address:

Insurance Company:

Address:

Claim No.:

Adjuster:

Adjuster Phone No.:

Statements made by the defendant at the scene:

VEHICLE INFORMATION FOR CLIENT:

Driver:

Passenger:

Year:

Make:

Model:

Does vehicle require repair::

Estimate:

Current Location of vehicle?:

If passenger, who was driving?

Who owns the vehicle?

INSURANCE INFORMATION: (Copy insurance card)

Was the vehicle you were traveling in insured at the time of the accident?:

By What Company? Policy Number:

If you were a passenger, do you have your own insurance policy on your vehicle?:

By What Company? Policy Number:

Are you living with anyone who has an insurance policy on an automobile?:

By What Company? Policy Number:

Did you report the accident to your insurance company or the insurance company for the driver?:

Claim No.:

Adjuster:

Adjuster Phone No.:

If available, process MEDPAY?:

CLIENT'S EMPLOYMENT INFORMATION:

Employer's Name:

Employer's Address:

Supervisor:

Supervisor Phone No.:

Job Title:

Salary: Length of Employment:

Did your doctor take you out of work as a result of the accident?:

Which doctor?: How long were you out of work?:

PRIOR MEDICAL HISTORY:

List any other previous injuries or accidents (this includes anything work-related, other automobile accidents, falls, etc.)

PRIOR LEGAL HISTORY:

Have you ever filed a claim with an insurance company for another injury or accident?

If so, with what company?

Have you ever been involved in another lawsuit?

Details of other lawsuit (former lawyer), if any:

SOCIAL NETWORKING SITES:

Do you have a Myspace, Facebook or Twitter account? If so, what is your username/profile name?

HEALTH INSURANCE INFORMATION: (Copy Insurance Card/s)

Do you have health insurance?

Health Insurance Company Name

Member ID number:

Group number:

Effective date:

Address

Member Services Phone number on back of card:

Do you have a prescription plan separate from your health insurance?

Health Insurance Company Name

Member ID number:

Group number:

Effective date:

Member Services Phone number on back of card:

Worker's Compensation Claim?

Carrier:

Claim No.:

Coverage:

Have You Ever Declared Bankruptcy?

The information submitted in this form is secure and confidential.

New Client Information

CLIENT INFORMATION

ACCIDENT INFORMATION

MEDICAL INFORMATION

DEFENDANT INFORMATION

VEHICLE INFORMATION FOR CLIENT:

INSURANCE INFORMATION: (Copy insurance card)

CLIENT'S EMPLOYMENT INFORMATION:

PRIOR MEDICAL HISTORY:

PRIOR LEGAL HISTORY:

SOCIAL NETWORKING SITES:

HEALTH INSURANCE INFORMATION: (Copy Insurance Card/s)

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