Non Motor Vehicle Intake Form

Personal Information

Your Name*

First Last

Sex*

Male
Female

Spouse/Guardian

Address*

Street Address City State ZIP Code

Email*

Date of Birth*

Social Security Number*

Phone Number*

Work Number

Cell Number

Alternate Contact:

Contact's Name

Phone Number

How did you find us?

Accident Information

Date of Accident*

Time*

: HH

MM

Place of Accident*

Accident Description*

Where is Your Pain*

Do You Have Photographs of the Defect, Location, Conditions, or Injuries?*

Yes
No

Upload Your Photos

Drop files here or

If you can't upload the photos now you can bring them in physically or you can reply to our confirmation email and attach the photos then.

Do You Have Any Witnesses?*

Yes
No

Witness Name*

Witness Phone*

Witness Address

2nd Witness Name

2nd Witness Phone

2nd Witness Address

3rd Witness Name

3rd Witness Phone

3rd Witness Address

Please Describe the Condition That Caused Your Accident

If you were with someone at the time of your fall, who was it?

Name

Phone Number

Address

When Did You First Notice the Condition?*

What Was the Lighting Like Where You Fell?*

What Kind of Footwear Were You Wearing?*

Were You Carrying Anything?*

Yes
No

What Were You Carrying?*

Did You Notify Anyone of the Fall?*

Yes
No

Who Did You Notify?*

Was an Incident Report Prepared?*

Yes
No

Do You have a Copy?*

Yes
No

Was a Police Report Filed?*

Yes
No

Police Precinct:

Accident #

If You Know, Did You Fall On:

Private Property
Commercial Property
City Property
Other

What was it?*

In Your Opinion, Who is Responsible for the Area Where You Fell?

Do You Know of Anyone Else Who Fell in the Same Area Before or After You?*

Yes
No

Who?

Were You Treated at a Hospital?*

Yes
No

Were You an Inpatient or Outpatient?*

Inpatient
Outpatient

Name of Hospital*

Address of Hospital*

Date of Admission*

Were You Treated by a Doctor(s) or Other People Furnishing Health Services?*

Yes
No

Their Name*

Phone Number

Address

2nd Person's Name

2nd Person's Number

2nd Person's Address

Amount of Health Bills to Date*

Will You Have More Health Treatments?*

Yes
No

At the Time of the Accident, Were You in the Course of Your Employment?*

Yes
No

Did You Lose Time From Work?*

Yes
No

How Much Time?*

Date Absence Began*

Have You Returned to Work?*

Yes
No

Date You Returned*

Were You Receiving Unemployment Benefits at the Time of the Accident?*

Yes
No

What are Your Average Weekly Earnings?*

Number of Days You Work per Week*

Please enter a number from 0 to 7.

Number of Hours per Day*

Please enter a number from 1 to 24.

Please list the name and address of your employer and other employers for one year prior to the accident date giving occupation and dates of employment.

Employer Name*

Employer Address*

Occupation*

Dates of Employment*

Employer Name

Employer Address

Occupation

Dates of Employment

As a Result of Your Injury, Have You Had Any Other Expenses?*

Yes
No

What Were They?*

Due to this accident, have you received or are you eligible for payments under any of the following?*

New York State Disability
Workers Compensation

What is Your Private Health Insurance Company?*

Are You Receiving Public Assistance and/or Medicaid Benefits?*

Yes
No

Any Prior Accidents or Injuries? If Yes Please Briefly Explain.*

Signature

The above stated information is all true to the best of my knowledge.
Please sign and date below.

Signature*

Date*

Note to Clients:

Clients deserve to be kept informed and updated on the status of their cases. We will make a continued effort to assure that you understand what is happening with your case.

Please let me know whether you prefer periodic written updates, telephone updates, e-mail updates or scheduled office appointment updates.

Please Select Your Choice(s)*

Written Updates
Telephone Updates
Emailed Updates
Scheduled In-Office Appointments

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