Civil Intake Form

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CLIENT INFORMATION

Client Name:*

Home Address:

Home Phone Number:

Cell Phone Number:

Email Address:

Date of Birth:

Place of Birth:

Social Security Number:

Driver’s License Number:

State of Issuance:

SPOUSE INFORMATION

Spouse’s Name:

Spouse’s Cell Phone Number:

Spouse’s Email Address:

SECONDARY/EMERGENCY CONTACT INFORMATION

Secondary/Emergency Contact Name:

Secondary/Emergency Contact Address:

Secondary/ Emergency Contact Phone Number:

CLIENTS EMPLOYER INFORMATION

Employer/Company Name:

Employer Phone Number:

Length of time employed:

DESCRIBE YOUR COMPLAINT

Date of Injury:

Location injury/accident occurred:

Facts of your case:

CLIENTS AUTO/HOME INSURANCE INFORMATION, IF NECESSARY

Name of auto insurance company:

Policy Number:

Name of home insurance company:

Policy Number:

CLIENTS HEALTH INSURANCE INFORMATION, IF APPLICABLE

Name of Insurance Company:

Policy Number:

OTHER PARTY’S GENERAL INFORMATION

Name:

Address:

Phone Number:

MOTOR VEHICLE ACCIDENT, IF APPLICABLE

Defendant Name:

Defendant’s Address:

Defendant’s Phone Number:

Defendant’s Driver’s License Number:

Defendant’s Insurance Company:

Defendant’s Policy Number:

Defendant’s License Plate Number:

Insurance Claim Number:

Date claim was made:

OTHER PARTY’S INFORMATION CONTINUED (if needed)

Other Party’s Name:

Other Party’s Address:

Other Party’s Driver’s License Number:

Other Party’s Insurance Company:

Other Party’s Policy Number:

ACCIDENT, INJURY, OR COMPLAINT EVENT DETAILS

CLIENT NAME:

DATE OF THE EVENT:

TIME:

DAY OF WEEK:

LOCATION:

CITY:

COUNTY:

STATE:

PLEASE DESCRIBE THE EVENT THAT HAS LEAD TO YOUR COMPLAINT: