New Client Premises Liability Questionnaire

Please complete the following questionnaire regarding your Premises Liability case.

Premises Liability Questionnaire

Please complete this questionnaire regarding your premises liability case.

"*" indicates required fields

Personal Information

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone Number*

Email*

Emergency Contact (Name and Phone Number)*

Have you ever declared bankruptcy? If so, has the bankruptcy been resolved?*

DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.

Social Security Number*

Please enter your full SSN or at minimum the last 4 digits.

Marital Status

Employment Information

What Is Your Current Employment Status?*

Did You Miss Work Following The Incident?*

Employer's Name and Phone Number*

Incident Information

Incident Description*

Please provide a brief description of what happened.

Incident Location & Date*

Where on Premises Did Incident Occur?

Ex: store aisle, stairwell, parking lot

Did You Complete an Incident Report?*

Upload Pictures From Scene, Injury Photos

Drop files here or

Max. file size: 20 MB.

Upload Copy Of The Incident Report

If you are unable to upload the report, please text or email us a copy.

Drop files here or

Max. file size: 20 MB.

Health Insurance

Do You Have Health Insurance Coverage?*

Select Your Health Insurance Provider(s)*

Medicare

Medicaid (Peach State Health Plan, Dept. of Community Health)

Private Insurance (Humana, BCBS, etc.)

Tricare/VA

None

Member ID Number (s)*

If you selected Private Insurance above, please include the name of your provider. If you have supplemental coverage or multiple providers, please specify which provider is associated with each Member ID Number. (Ex: Medicare 0012345, Humana 0098765)

Upload Pictures of the FRONT AND BACK of Your Health Insurance Card (s)

Drop files here or

Max. file size: 20 MB.

Medical Treatment & Injury Information

Were You Transported by Ambulance/EMS After The Incident?*

Have You Had Medical Treatment For Your Injuries?*

This includes Emergency Room, Urgent Care, Chiropractor, Orthopedic Specialist, Physical Therapy, Etc.

List of Medical Providers*

Enter the name and location of each facility/provider that you have treated with. Use the “plus” button to add additional providers. It is VERY IMPORTANT that you list ALL medical providers you have treated with. (Ex: Emory Hospital Midtown, 550 Peachtree St NE, Atlanta, GA)

Injury Description*

Enter a brief description of your injuries. (Ex: Lower back pain, headaches, broken arm, Etc.)

Have You Experienced Any Prior Accidents or Serious Injuries?*

Please be truthful in your response to this question. Your answer is VERY important and necessary for us to give your case the best outcome. This information will not be shared with anyone outside our law firm.

If You Answered Yes Above, Enter The Nature of Your Prior Injury, Approximate Date, and Whether an Insurance Claim or Lawsuit Was Filed.

(Ex: Rear-ended in 2010, back injury, other driver’s insurance paid for my repairs.)

Upload Any Other Relevant Documents or Photos Here

Max. file size: 20 MB.

Name

This field is for validation purposes and should be left unchanged.