Personal Injury Interview Form: Slip, Trip, and Fall

Date

First Name

Last Name

Date of Birth

Street Address Street Address Line 2

City

State

Zip Code

Country

Phone (home)

Phone (cell)

Phone (work)

Email

Claim Number

Social Security Number

Spouse First Name

Spouse Last Name

Children's Names & Ages

Who referred you to our office?

Date of incident

Time of incident

Location

Name, address, phone of property owner

Property owner's insurance company

Description of incident

Describe injuries caused by incident

Name of doctors, hospitals, and others who have treated you for this incident

Previous injuries (describe injury and when occurred)

Names of doctors who have treated you BEFORE this incident

Employer on date of incident

Job title

Date you first began working there

Date you last worked

Salary/Wage on date of incident

Wages/days lost

Do you owe back child support and/or does OSE have any liens for payment of back child support?

Your medical insurance company

Did you give a statement to an insurance adjuster? If so, to whom?

Have you been represented by another attorney for this claim? If so, who?

Other information which would assist us in evaluating your claim