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New Client Info Form

Please Answer ALL Questions

Personal Information

First Name *

Last Name *

Address *

City *

State *

Postal code

Phone *

Social Security Number

Email *

Date of birth

How long have you lived in Florida

DOA

Time of Accident

City of Accident

PD

Crash or Agency #

Spouse Name

Children

Employment Information

Employer

Time Lost Due to Accident

Your Insurance Carrier

Auto Ins Co

Auto Policy Number

Auto Claim Number

Number of Cars/Description

Health Ins Co

Health Ins Policy

Defendant(s)

Def Name

Def Address

Def Ins Pol Claim

Was Defendant Corp Driver

Accident Information

How Did Accident Happen?

Wearing Seatbelt?

Yes

No

Texting While Driving?

Yes

No

Defendant Texting and Driving?

Yes

No

Are You a Uber/Lyft or Commercial Driver?

Yes

No

If you Drive Uber/Lyft Did You tell your Insurance?

Yes

No

Witnesses

Passengers

Property Damage

Rate the Damage

Minor

Moderate

Severe

Is the Vehicle Driveable?

Yes

No

Is Vehicle at Towyard?

Yes

No

If in Towyard, Which One

Hospital Info

Did You Go To The Hospital

Yes

No

What Hospital and Date

ER Only Not Admitted

Yes

No

Were You Admitted and Date?

Injuries

Ambulance

Yes

No

Fire Rescue or Emergency Services

Yes

No

Physicians and Specialists

Prior Claims Suits or Injuries of ANY Kind!

Prior Dates

Prior Injuries

Prior Attorneys

Prior Physicians

Prior Settlements

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