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

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:

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

Military Service?

Yes

Dates of Service: Branch: Any Military-Service Related Injuries?

No

Accident Details/Description

Date of Accident

Time of Accident

Approximately

Location of Accident

Include nearest cross streets if possible.

Describe how the accident occurred

Include directions of travel, lanes of travel, and approximate speed of each vehicle if possible.

Describe what happened immediately after the accident

Include any conversations with any parties and/or witnesses

What is your best estimate of how fast the other car was travelling when it hit you?

Note - this is only your best approximate estimate. Please answer in miles per hour (MPH)

Were you driving?

Yes

No

Were there any passengers in your vehicle?

Yes

Passenger 1's Full Name Passenger 2's Full Name Passenger 3's Full Name Passenger 4's Full Name

No

Were you working at the time of the accident?

Yes

No

If you were working at the time of the accident, please explain what you were doing for your employer.

Was a Traffic Collision Report made?

Select an Option Yes No

If yes, which Law Enforcement Agency?

For example, CHP, LAPD, LASD, etc.?

Were you given a white or colored card by the law enforcement agent?

Yes

Please upload a picture of the card here.

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No

Were you transported by ambulance?

Yes

By whom?

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

No

Do you have any contact information for any witnesses?

Yes

Name, address and phone number: Name, address and phone number: Name, address and phone number: Name, address and phone number:

No

Your Vehicle Information

Vehicle Year

Vehicle Make/Model

Vehicle Color

Vehicle License Plate No.

Rate your vehicle's property damage as a result of the accident:

Select an Option Minor ($0 - $4k) Moderate ($5k - $10k) Major ($10k - totaled)

Was your vehicle towed from the accident?

Select an Option Yes No Unknown

Where is your vehicle currently located?

Include street address, if possible.

Have you obtained an estimate for your vehicle's property damage?

Yes

Please upload the property damage estimate

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No

Do you have any pictures of your vehicle's property damage?

Yes

Please upload the pictures

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Please upload the pictures

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Please upload the pictures

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No

Your Injuries

Please select the primary areas of pain you are experiencing/experienced after the accident.

Low backUpper backNeckLeft upper extremitiesRight upper extremitiesLeft lower extremitiesRight lower extremitiesHeadOther

Do you have any pictures of your injuries?

Yes

Upload here:

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No

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

Upload here:

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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.

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Your Vehicle Insurance

Did you have a valid auto insurance policy in effect at the time of the accident?

Select an Option Yes No Unknown

Who is your auto insurance company?

I.e. Progressive, State Farm, AAA, etc. - if you do not have auto insurance, please answer "Uninsured."

Please upload a picture of your auto insurance card.

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Have you reported the accident to your insurance company?

Yes

Name of who you contacted Phone number of who you contacted Email of who you contacted

No

Did you give a recorded statement about the accident to your auto insurance company?

Yes

No

Do you have a claim number with your auto insurance for this accident?

Yes

Enter claim number

No

What is your auto insurance policy number?

If you do not have auto insurance, please answer "Uninsured"

The Other Person's Vehicle Insurance

What is the other person's name?

Please give your impression of the other driver who hit you

I.e. wealthy v. not wealthy, friendly v. rude, etc.

Who is the other person's auto insurance company?

I.e. Progressive, State Farm, AAA, etc.

Do you have a claim number with the other person's auto insurance for this accident?

Yes

Enter claim number

No

Do you have pictures of the other person's insurance card and/or driver's license?

Yes

Please upload the other person's insurance card

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Please upload the other person's driver's license

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No

Have you contacted and/or been contacted by the other person's auto insurance company?

Yes

Name, email and/or phone number of who you contacted and/or were contacted by

No

Did you give a recorded statement about the accident to the other person's auto insurance company?

Yes

No

If you gave a recorded statement, when?

THANK YOU