Intake form - Smith & Valentine Law

Contact Us

Salutation (Mr, Mrs, etc)

First Name:

Last Name:

Preferred Name:

Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Date of Birth:

Social Security Number:

Drivers License:

Marital Status

Spouse Name

At the time of the accident, were you in the course of your Employment?

Have you lost time from work as a result of your injuries?

Employer Name:

If you have lost time from work or in the course of employment, please provide Employment information.

Position:

Employer Address:

Employer Phone #:

Nearest Living Relative – First name, Last Name, and Relationship:

Please provide the First name of your nearest living relative and your relationship – Spouse,
Child (daughter/son), Parent (Mother/Father), Aunt, Uncle, Niece, Nephew, etc.

Nearest Living Relative Last Name:

Nearest Living Relative Phone #:

Date of Accident:

Type of Accident:

If Other, please list the Accident Type:

Location of Accident: (City/State)

If the accident occurred in a business, private home or property, please include a full address
and the name of the company and/or owner of the property the accident occurred in/on.

Incident Information:

Please describe the incident.

Was an Accident Report Filed?

Were you charged for the Accident?

Were you wearing a Seatbelt?

What was your location in the Vehicle?

Did you use the Ambulance?

Did the airbags deploy?

Was the vehicle totaled?

Were there any Witnesses?

Name of Witness(s):

List all injuries resulting from the Accident:

Please specify "Right" or "Left" when applicable. For Example: Headaches, back pain (upper, Mid, Lower),
Neck pain, shoulder pain (right/left/both), Arm Pain, Leg pain, etc.

Do you have any prior accidents or Injuries?

List all prior accidents and injuries:

Please list all date(s) of accident(s) and approximate dates even if no injuries resulted.

Did you go to the Hospital following the accident?

If Yes, when did you go to the Hospital?

Were you admitted at the Hospital?

Please list all medical facilities you have sought treatment for the injuries resulting from the Accident:

Include facility name, doctor name, and address

Name of your Auto Insurance Company:

(If you do not have Auto Insurance please type "N/A" in the space provided)

Your Insurance Policy Number:

Your Insurance Claim Number:

(If you don't have one just leave blank.)

Name of At Fault Insurance Company:

At Fault Insurance Policy Number:

At Fault Insurance Claim Number:

(If you don't have one just leave blank.)

Name of Health Insurance:

(If you do not have health insurance just type "N/A" in the space provided)

Health Insurance Member Number:

Health Insurance Group Number:

Name of Insured/Policy Holder:

How did you hear about us?

If a friend referred you, please include his/her name.