ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

Your Contact Info/General Background

Preferred Contact Method

Select an option Email Phone No Preference

Social Security Number

Driver's License Number

Are you currently employed?

Yes

Employer Name Job Title Employer Phone Number Employer Address Current Salary

No

Did you miss work at all as a result of the accident?

Yes

Enter dates you missed work

No

Prior Criminal Record?

Select an option Misdemeanor Felony No Unknown

Prior Traffic Collisions?

Select an option Within 2 years prior Within 5 years prior More than 5 years prior No Unknown

How were you referred to our law firm?

Friend or family member

Input the person's full name:

Another attorney

Input the attorney's full name:

Online search or lawyer directory website

Input the name of the website:

For example, "Avvo", "Facebook", or "LawFirmName.com"

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Where was the ad located?

Radio or TV advertisement

What radio or TV station?

Bar Association

Which Bar Association?

Other

Please explain how you found us:

Accident Details/Description

Date of Accident

Location of Accident

Name of restaurant, store, or other establishment - include specific location of premises (i.e. walkway, lobby, bathroom, etc.)

Why were you at this premises?

I.e. were you a customer, worker, attendee, etc.?

Have you been to this location before the accident?

Select an option Yes No

Description of Accident

Be as specific as possible including your body movements when you fell and/or were injured.

What caused you to fall?

I.e. water/liquid, raised/cracked floor, etc.

Is there any reason you believe that whatever caused your fall was there for a long period of time?

I.e. was their surrounding stains from a spill that had dried, had you seen/reported the spill before the accident, etc.

Yes

Explain

No

Did any employee(s) assist you after the accident?

Yes

Explain what they said, if anything, about what caused your fall.

No

Was an incident report made?

Select an option Yes No Unknown

Is there video footage of the accident?

Select an option Yes No Unknown

Were there any other witnesses who saw the accident?

Select an option Yes No

Was there any warning signage near the accident location?

Yes

Explain

No

What type of shoes were you wearing?

I.e. sneakers, dress shoes, high heels, etc.

Do you still have those shoes?

Select an option Yes No

Were you intoxicated/drinking alcohol?

Yes

Explain

No

Explain precisely where you were looking 5 - 10 seconds prior to the accident

Your Injuries

Were you transported by ambulance?

Yes

By whom?

For example, AMR, LAFD, LA County Fire, etc.?

No

What are your primary areas of pain/injuries?

If you have any pictures of your injuries, please upload them.

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

Have you had any injuries prior to this accident to the same parts of your body?

Select an option Yes No Unknown

If so, please explain the prior injuries

Do you have any chronic medical conditions that cause you pain?

Select an option Yes No Unknown

If so, please explain the chronic medical condition

Please describe the frequency and areas in which the chronic condition causes you pain.

Your Medical Treatment

Who is your primary care provider (PCP)?

Include healthcare facility, address, telephone number and doctor's name.

Did you go to the emergency room or urgent care after the accident?

Yes

When?

No

Have you seen any other medical providers since the accident?

I.e. doctor's office, chiropractor, physical therapist, etc.

Yes

First medical provider's name and address Second medical provider's name and address Third medical provider's name and address Fourth medical provider's name and address

No

Do you have any records from any medical provider you have seen?

Yes

Please upload any records you have

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

Please upload any records you have

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

Please upload any records you have

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

Please upload any records you have

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

No

Your Health Insurance Information

What type of health insurance do you have?

Select an option Private HMO/PPO Medi-Cal/Medicare Uninsured

If you have health insurance, what is your policy/group number?

If you have health insurance, what is your ID No.?

If you are covered under Medi-Cal or Medicare, please enter your Medi-Cal/Medicare No.

If you have health insurance, please upload a picture of the front and back of your health insurance ID card.

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

THANK YOU