Life for an injury victim often times becomes much more difficult after the injury, and the extent of one's injuries is not always clear until days or even months after the incident occurs. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with doctors, insurance companies, and possibly attorneys. Additionally, injury victims may need to provide documentation to their employer in order to justify (or be reimbursed) for recovery time.
Each of the parties involved will require the victim or a representative to provide them with documentation. If you are an injury victim and planning to file a claim, your attorney will ask a number of detailed questions; so preparing early will make the process much easier (while helping you remember key details).
If you are the person providing the documentation, filling out the form below will prepare you for most of the questions these individuals need answered. You can print this form in either PDF or Microsoft Word format and print it out.
Also available in PDF | MS Word Name _____________________________________________ Date of birth ____/____/____ Social security number _____-____-_______ Address ____________________________________________ ___________________________________________________ ___________________________________________________ Home phone (_____) ______-________ Work phone (_____) ______-________ Mobile phone (_____) ______-________ E-mail address ____________________ Best method to reach you ________________________ Best times to reach you __________________________ Married ____ Single ____ Divorced ____ Number of children ____ If married, spouse's name _________________________ On what date did your injury occur? ____/____/____ Where did your injury occur? City _____________ State _____ How did your injury occur? __ Aircraft accident __ Animal bite or attack __ Assault and battery __ Defective premises __ Defective product __ Police negligence or abuse __ Medical malpractice __ Motor vehicle accident __ Slip or trip and fall __ Water-related accident __ Other ________________________ Describe how your injury occurred. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Who do you believe caused or is responsible for your injury, and why? __________________________________________________________ __________________________________________________________ __________________________________________________________ Describe your injury(ies). __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Total medical expenses incurred to date for your injuries: $________________ Total medical expenses you expect to incur in the future: $________________ List the names, addresses, and telephone numbers of all insurance companies that may be involved (including, as applicable, automobile insurer, health insurer, disability insurer, homeowner's insurer, etc.). _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Have you lost income due to your injuries? Yes __ No __ If yes, amount of lost income $_________ Income before injury $__________ per ___________ Income after injury $__________ per ___________ Employer __________________________________________ Position ___________________________________________ Employer's address _____________________________________ ____________________________________________________ ____________________________________________________ Employer's telephone number (_____) _______-________ Are you currently working? Yes ___ No ___ Expect to return to work on ___/___/___ Will not return to work ___ Are you in pain? If so, describe. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.) __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ If married, has your spouse experienced any losses as a result of your injury? If so, describe. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ List the names, addresses, and phone numbers of any possible witnesses in your case. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Have you previously consulted an attorney regarding your case? Yes ____ No ____ If yes, provide the attorney's name(s), the firm name(s), the address(es), and the telephone number(s). __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Is your relationship with the attorney ongoing? Yes ____ No ____ Has an attorney declined to represent you in this matter? Yes ____ No ____ If yes, why? __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Questions you have about your case: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ |
Get Professional Legal Help With an Injury Today
Understanding who's liable for what in a personal injury case can be a complex issue. Failing to obtain such an understanding, however, could prove costly for an injured party. An experienced injury law attorney will know the relevant laws in your state and help protect you from unintended outcomes.
