Keefe Law Firm Personal Injury Interview Sheet (KB371372 ...
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keefe-
866-575-5000
|Red Bank |Newark |Pt. Pleasant |Bayonne |
|125 Half Mile Road, Suite 100 |76 Ferry Street |2400 Route 88 |561 Broadway |
|Red Bank, NJ 07701 |Newark, NJ 07105 |Pt. Pleasant, NJ 08742 |Suite 2 |
|732-224-9400 |973-274-0408 |732-202-7205 |Bayonne, NJ 07002 |
|732-224-9494 fax |973-274-0409 fax |732-224-9494 fax |201-720-3678 |
| | | |732-224-9494 fax |
PERSONAL INJURY INTERVIEW SHEET
Date of Accident:_____________________ SOL: ___________________ Today’s date:______________
Referred by: __________________________________________________________________________
Intake Resource: _______________________________________________________________________
Interviewed by: _______________________________________________________________________
PERSONAL INFORMATION
Name: __________________________________________________________ Age: _______________
Date of Birth: ____________________________ SSN or Tax ID: __________________________
Place of Birth: ___________________________ _______ __________________________
City State Country
Languages Spoken: ____________________________________________________________________
Current Address:
_____________________________________________________________________________________
Tel./home: ______________________________ Tel./work: _____________________________
Tel./cell: ________________________________ Email: ________________________________
Marital Status: Married ___ Single ___ Divorced ___ Separated ___
Widow/widower ___ Common Law Marriage ___ Engaged ___
Spouse’s name:________________________________________________________________________
Date of Marriage: ______ / ______ / ______ Place of Marriage: _____________________________
Do you have children? Yes _____ No _____
1. Name: ________________________________________________________ DOB: ______________
2. Name: ________________________________________________________ DOB: ______________
3. Name: ________________________________________________________ DOB: ______________
4. Name: ________________________________________________________ DOB: ______________
Emergency Contact:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Telephone(s): ________________________________________________________________________
Relationship: _________________________________________________________________________
ACCIDENT INFORMATION
Date of Accident: ____ / ____ / ____ Place/City: ____________________________ State: ________
Accident Time: __________AM/PM Weather at the time of accident: __________________________
Type of Accident: Motor-vehicle ____/Fall down ____/Construction ____/Factory ____/ Other ______
Describe how the accident happened:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe your injuries:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Witnesses: 1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
Were you taken to a hospital? Yes _____ No _____ When? ___________________________________
Which hospital? _______________________________________________________________________
Were photos taken of the accident scene? Yes ____ No ____ Do you have copies? Yes ____ No ____
Is there a Police Report? Yes _____ No _____ Do you have a copy? Yes _____ No _____
Hospitalizations and admission dates:
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
Name/Address of all current treating doctors:
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
5. ___________________________________________________________________________________
Present Medical Complaints: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Past Injuries and Dates:
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
EMPLOYMENT INFORMATION
Were you injured in the course of your employment? Yes ____ No ____
Employer on date of accident: ____________________________________________________________
Employer’s Address: ___________________________________________________________________
Telephone(s): _________________________________________________________________________
Time lost from work: ___________________________________________________________________
Wages on date of accident: $ ___________ per: hour ___ day ___ week ___ month ___ task ___
Employer’s Insurance Company(s): _______________________________________________________
Employer’s Insurance Policy Number(s): ___________________________________________________
Address: _________________________________________________ Tel.: ______________________
Current Employment: ___________________________________________________________________
Contact Information: ___________________________________________________________________
Accident-related out-of-pocket expenses:
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
CLIENT’S INSURANCE INFORMATION
Client’s Tort Threshold (Attach plaintiff’s Declaration Sheet):
Verbal: _____ Non-Verbal: _____ Zero: _____
Property Damage Claim? Yes ____ No ____
Auto Insurance Carrier: _________________________________________________________________
Named Insured: _______________________________________________________________________
Address: _____________________________________________________________________________
Policy No.: ___________________________________________________________________________
Client’s Health Insurance Carrier: _________________________________________________________
Named Insured: _______________________________________________________________________
Address: _____________________________________________________________________________
Policy No.: ___________________________________________________________________________
ADDITIONAL INFORMATION
Do you have previous Litigation Attorneys? Yes _____ No _____
1. Name / Address / Phone #: ____________________________________________________________
_____________________________________________________________________________________
2. Name / Address / Phone #: ____________________________________________________________
_____________________________________________________________________________________
Remarks:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature:_____________________________________________ Date: ______ / ______ / ______
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