LeClair & LeClair, P.C. - Automobile Accident Form

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Automobile Accident Form

If you are interested in having LeClair & LeClair, P.C. handle your case, please feel free to fill out the following client information form. If you have sent us a client information form and have not heard from us within 24 hours, please make sure that you telephone us to insure we received your information. Prior to LeClair & LeClair, P.C. accepting any case and assuming responsibility for that case, you will have to have a consultation with one of our attorneys and a written fee agreement will have to be executed by you and LeClair & LeClair, P.C.. While not all injuries give rise to a cause of action, we are willing to provide you with a free, no commitment consultation to discuss your case. Whether or not LeClair & LeClair, P.C. agrees to handle your case, any information that is provided to us will be kept confidential and will not be given to any third party without your consent.

General Information
E-Mail Address:
Today's Date:
Name:
Address:
City:	State: Zip Code:

County:
Home Phone:
Work Phone:
Date of Birth:
Date of Injury:
Social Security Number:
Spouse's Name:
Number of Children:
How did you hear of LeClair & LeClair, P.C. Law Firm?
The Accident
Explain how the accident/injury occured:
Were you driving or passenger?
Was there a police report?	yes no
Did you get a copy?	yes no
Was there a traffic ticket issued?	yes no
To Whom?
For what?
Did the defendent say anything admitting fault?	yes no
If yes, what did he/she say?
Did the defendent's insurance company pay your property damage? yes no
Amount they paid:
If not, who paid?
* please provide pictures of the damaged vehicles if you have them.
What are the names of the witness(es) to the accident:
Injuries
Did you go to the emergency room?	yes no
If yes, where?
Did you go in an ambulance?	yes no
What are your injuries from this accident?
Please list the doctors and all medical providers you have seen for injuries from this accident:
What is the total amount of your medical bills to date?
Have any of them been paid yet?	yes no
By who / what insurance company?
Work Losses
Have you lost any time from work?	yes no
Hours/days lost from work?
Employer's name:
What is your hourly pay rate?
Has your doctor given you any work restrictions?	yes no
If yes,what are they?
Other Injuries
Have you had any other similar injuries? (before or after this)	yes no
Have you ever had any other insurance claims? (before or after this)	yes no
Have you had any other accidents? (before or after this)	yes no
For the above 3 questions, describe the situation:(include dates)
Activities / Lifestyle
Have any of your activities been interupted due to this accident? yes no
If yes, please describe. Note each activity and if you can't do or can do with pain:
Witnesses to activity/lifestyle changes
Pictures If you have any pictures showing the injured person in action before the injury please provide them.
Insurance Information
Your Auto Insurance:
Company name:
Adjuster:
Address:
Phone number:
Insurance claim number:
Your Health Insurance:
Company name:
Adjuster:
Address:
Phone number:
Insurance policy number:
Insurance claim number:
Defendant's Auto, Homeowners, Or Other Insurance:
Company name:
Adjuster:
Address:
Phone number:
Insurance claim number:

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Automobile Accident Form

General Information

The Accident

Injuries

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Activities / Lifestyle

Insurance Information

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