Intake - Smartadvocate - Shuman Legal Personal Injury Lawyers

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First Name:

Last Name:

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Address:

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Date Of Birth:

Last four digits of their social security number:

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Case Type

How were you injured?

What are your injuries?

# of Dependents (under 18):

City where you were injured:

State where you were injured?

Male

Female

Married

Single

Average Weekly Wage (your gross wages excluding OT and bonus)?

How much do make per hour?

How many hours per week do you work?

Who did you report your injury to (supervisor)?

Are you required to work over time? If so, how many hours per week on average?

Where was the first place you went for treatment?

Have you been anywhere else for treatment? If so, where?

When did you start working for your employer?

Are you still receiving medical treatment or have you been released from care?

WC Insurance Company:

WC Insurance address

WC Insurance Adjuster name?

WC Insurance Adjuster phone number?

WC Insurance claim number?

Did you return to work? If so, when?

Have you ever had any prior WC claims?

Is your employer paying your worker's compensation checks (TTD)?

Is your employer paying your medical bills?

Employer's Name:

Employer's Address:

Was the employer notified of the accident Orally?

Was the employer notified of the accident in writing?

When did the resident first enter the nursing home?

Why did the resident enter the nursing home?

What is the name and address of the nursing home?

When were you first informed or first notice the nursing home resident's injury?

If YOU noticed the nursing home resident's injury, did you report it to anyone at the nursing home?

If you reported the nursing home resident's injury to someone at the nursing home, please provide the name and title of the person to whom you reported the injury.

If you reported the nursing home resident's injury, when did you report it?

Was the nursing home resident hospitalized at any time while a resident of the nursing home?

If the nursing home resident was hospitalized at any time while he/she was a resident of the nursing home, please provide the name(s) of the hospital(s) and date(s) of hospitalization.

Why do you believe the nursing home was negligent?

Do you think a hospital or some other medical care provider was also negligent?

If you believe that a hospital or other medical care provider was also negligent, please explain in detail.

How are the nursing home resident's bills being paid?1

Is the resident competent?

Does anyone have POA or is there a guardian?

If Yes, who?

Were you the driver or a passenger?

How many people were in your vehicle?

What street were you on?

What direction were you traveling?

If you were a passenger, were you sitting in the front or back of the vehicle?

Were you rear ended?

What street was the other vehicle traveling?

What direction was he/she traveling?

If a police report was made, what is the name of the police department?

What is the police report number (RD Number or Agency Crash Report number)?

What time was the accident?

Were any citations issued?

Did you go to the hospital following the accident? If so, which one?

Have you seen a doctor yet?

If the car that you were in had insurance, have you filed for no-fault benefits?

If you went to the hospital, how did you get there?

Have you sought medical treatment since the incident?

If you sought medical treatment since the incident, what is the name and phone number of the provider?

Have you been seeking medical treatment on a continual basis since the accident?

Do you expect to seek additional medical treatment for these injuries?

Have you missed any time from work due to this accident?

If you lost time from work, who is your employer?

Were any photographs taken of the scene and/or vehicle(s)?

If there were any witness to the accident, do you have their name(s) and contact information?

Have you had any prior injuries/accidents/claims?

What was the make and model of the car you were in?

What is the name of the car insurance of your car (or the car you were in)?

If there was car insurance on your car (or the car you were in), what is the claim number?

Did you have full coverage or liability only on your car?

If there were any other people in the motor vehicle you were in, were they injured?

Additional case details?

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ATTN: Work injury?

Concussion?