Personal Injury Intake Sheet

124 Lake Street South
Long Prairie, MN 56347
Phone: 1-320-732-6112 Fax: 1-320-732-6023

CHECKLIST FOR INITIAL CLIENT INTERVIEW
ON PERSONAL INJURY CLAIM
Print this out and fill in to bring to us for your appointment

Plaintiff Information

Full Name:__________________________________________

Address:______________________________________________________________________________

Home Phone________________Work Phone_________________Employer_________________________

Social Security #________________________Drivers License #__________________________________

Defendant Information

Full Name:__________________________________________

Address:______________________________________________________________________________

Telephone___________________Employment (if known) _______________________________________

Drivers License #_______________________________

If auto accident, obtain above information for both OWNER and DRIVER of vehicle.

Date and Time of Accident_______________________________________

Location of Accident_____________________________________________________________________

Vehicles Involved

Plaintiff's vehicle Make Year Color License

(Ownership) ________________________________________________________________

Defendant's vehicle Make Year Color License

(Ownership) ________________________________________________________________

Plaintiff's Personal History

Date and Place of birth:___________________________________________________________________

Educational History:______________________________________________________________________

Other family members, marital history, children:_________________________________________________

_____________________________________________________________________________________

Occupational/Employment History:___________________________________________________________

_____________________________________________________________________________________

History of all prior injuries or hospitalizations:____________________________________________________

______________________________________________________________________________________

Accident Facts:

Where Plaintiff was coming from and where going to:______________________________________________

_______________________________________________________________________________________

Weather conditions:_______________________________________________________________________

Road conditions:_________________________________________________________________________

Identity and position in vehicle of any passengers:_________________________________________________

______________________________________________________________________________________

_______________________________________________________________________________________

Direction of Travel:________________________________________________________________________

Approximate Speed:__________ Lane:________________________________________________________

Description of accident:____________________________________________________________________

______________________________________________________________________________________

Detailed description of all body movement within vehicle after impact:__________________________________

______________________________________________________________________________________

Detailed description of course of travel of all vehicles after impact:____________________________________

______________________________________________________________________________________

Detailed review of all conversations or discussions at scene of the accident:______________________________

______________________________________________________________________________________

Evidence of drinking, medications or drugs:______________________________________________________

Identity of all investigating police agencies and police officers and description of what was done by each:

______________________________________________________________________________________

Means by which plaintiff left the accident scene:__________________________________________________

Skid marks:_____________________________________________________________________________

Location of debris:________________________________________________________________________

______________________________________________________________________________________

Tickets issued:___________________________________________________________________________

Identity of all witnesses and location of all witnesses:_______________________________________________

______________________________________________________________________________________

Description of vehicle damage:_______________________________________________________________

______________________________________________________________________________________

Injuries

Detailed listing of each injury including date and time of onset of symptomatology:_________________________

______________________________________________________________________________________

Medical Treatment

Chronological resume of all medical treatment from the time of the accident to the present date:

______________________________________________________________________________________

Listing of each doctor and/or hospital with address and phone number from which Plaintiff has received treatment since the accident:____________________________________________________________________________

______________________________________________________________________________________

Photographs and other Evidence

Listing of all photographs taken to date:_________________________________________________________

_______________________________________________________________________________________

Photographs being ordered:__________________________________________________________________

_______________________________________________________________________________________

List all other items of evidence in Plaintiff's possession:_______________________________________________

_______________________________________________________________________________________

Special Damages

Listing of all medical expenses incurred to date:____________________________________________________

_______________________________________________________________________________________

Listing of all time lost from work and amount of wages lost:___________________________________________

_______________________________________________________________________________________

Other expenses incurred as a result of accident to date:______________________________________________

_______________________________________________________________________________________

Amount of property damage incurred:___________________________________________________________

Insurance

Identity of Plaintiff's no-fault insurance carrier:_____________________________________________________

Policy number:______________ Adjuster____________________ Claim Number_______________________

Identity of every other insurance policy carried by Plaintiff or any member of plaintiff's household covering any vehicle owned by any member of the household:_________________________________________________________

________________________________________________________________________________________

Identity of any other applicable insurance covering Plaintiff (Auto Club, etc.)

________________________________________________________________________________________

Identity of defendant's liability insurance carrier and policy number, adjuster and claim number, if known:

_______________________________________________________________________________________

Initial Interview Checklist

A. Client occupying Non-owned vehicle

_____ 1. Identify Owner and Insurer
_____ 2. Obtain Liability UM and UIM Limits
_____ 3. Identify all resident relatives owning vehicles, their insurers, limits of coverage and obtain copy of
all insurance polices.

B. Client Occupying Owned Vehicle

_____ 1. Insured - Obtain Copy of Insurance Policy
_____ 2. Uninsured - Identify all resident relatives owning insured vehicles; obtain copy of all insurance policies;
no-fault coverage available but disqualified for UM/UIM

C. Client Occupying Motorcycle

1.Owner:
_____ a. No-fault coverage purchased
_____ b. UM/UIM coverage purchased, owner limited to this amount
_____ c. Medical Assistance or Health Insurance involved - subrogation rights.

2. Non-Owner:
_____ a. No-fault coverage purchased
_____ b. UM/UIM coverage purchased, first priority
_____ c. Identify all resident relatives owning insured vehicles: obtain copy of all insurance policies.
_____ d. Medical assistance or Health Insurance involved - subrogation rights

D. Defendant Operating a Non-Owned Vehicle
_____ 1. Identify Insurer of all automobiles owned by the driver, or any resident relative of the driver. Obtain limits.
_____ 2. Identify any umbrella policies that may be available to owner/driver. Obtain limits.

E. Non-vehicle Caused Injuries
_____ 1. Obtain and copy all health insurance contracts
_____ 2. Inquire as to any medical pay coverage available to the defendant.
_____ 3. Is Medicare, Medical Assistance, etc. involved - subrogation rights

        F. Alcohol Relate Injuries
_____ 1. Location where Alleged Intoxicated Person (AIP) served known
                (a) Give dram shop notice within 120 days of illegal sale or being retained by client
_____ 2, Location of illegal sale unknown
                (a) Alter retainer agreement to clearly state that we "have not been retained to pursue or investigate
                      dram shop claim."

        G. Serious/Catastrophic Injuries
_____ 1. Consider Application for Social Security Disability.
_____ 2. Consider Applications for Medical Assistance
_____ 3. Obtain Short and Long-term Disability Policies
                (a) Do they coordinate? (b) Do they subrogate? (c) Letter starting we will (not) protect their interests
_____ 4. Obtain Health Insurance Policies
                (a) Do they coordinate? (b) Do they subrogate? (c) Letter starting we will (not) protect their interests

H. Out of State Injuries
_____ 1. Auto claim, determine liability limits, less than 30/60 claim
_____ 2. Auto claim, possible subrogation by no-fault carrier; can be extinguished by settlement release.
_____ 3. Immediately determine Statute of Limitations
_____ 4. Research differences in comparative fault, joint and several liability, measure of damages, etc.

I. Exhibits in Client's Control
_____ 1. Property Damage Estimates
_____ 2. Photographs
_____ 3. Itemized Medical Bills
_____ 4. Statements taken prior to representations