Personal Injury Interview Sheet

Personal Injury Interview Sheet

(To be Completed by Attorney or Paralegal)

TODAY'S DATE:

Referred by Client's Name

Type of Incident

Date of Incident Statute Date

Type of Injuries

PLAINTIFF'S INFORMATION

Name

Address

Your First Impression of Client

Social Security NumberDate of Birth

Spouse's NameMarital Status

Home Phone NumberBusiness Phone No.

Place of Employment

Compensation $

Address of Employment

TitleHow Long Employed

Driver's License NumberState

Prior Accidents/ClaimsPrior Disabilities

Key Damage Witnesses:

(1)

Name Address

Relationship Telephone

(2)

Name Address

Relationship Telephone

(3)

Name Address

Relationship Telephone

DEFENDANT'S INSURANCE INFORMATION

Name of Insurance Co.

Address of Insurance Co.

AdjusterPhone No.

Type of Policy(s) Cars Owned

Claim No. PIP Forms Requested

Insured Limits

PLAINTIFFS UIM COVERAGE

UIM Coverage $

Name of Insurance Company

Amount of CoverageCars Owned

Adjuster's Name and Phone Number

List all medical care providers, including hospitals, dates of service, ambulance, doctors, x rays, prescriptions, etc. Give addresses and amounts of bills, if known. If not, just list the name of the doctor and/or provider. Information can be completed later by our...