LeClair & LeClair, P.C. - Slip and Fall Form

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Slip & Fall 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 Fall
Explain how the fall/injury occured:
What were the conditions like of the area you fell before it happened?
Do you know who owns the property where you fell?	yes no
if yes, who?
Did the owner of the property do anything to protect you or others from falling?	yes no
(for example, if the area was icy, had it been sanded or salted) explain: *Please provide any pictures you may have of the area where you fell.
Did the owner say anything admitting fault?	yes no
if yes, what did he say?
Did the owner/ owners insurance company pay any of your damages?	yes no
if yes, amount they paid:
if not, who paid?
What are the names of the witness(es) to the fall:
Your 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 fall?
Please list the doctors and all medical providers you have seen for injuries from this fall:
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 interrupted 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
Defendant's Insurance Company:
Company name:
Adjuster:
Address:
Phone number:
Insurance claim number:
Your Health Insurance Company:
Company name:
Adjuster:
Address:
Phone number:
Insurance policy number:
Insurance claim number:

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Slip & Fall Form

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The Fall

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