PREMISES INJURY INTAKE FORM(If you do not have some of the information we ask for, we will track it down for you.)PERSONAL INFORMATIONName(s)/ODL# Phone NumberD.O.B MM slash DD slash YYYY Marital Status SSN Name/adress/phone number of next to kin Have you had another lawyer work on this case? Yes No ACCIDENT FACTSDate MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Location (city/state/neighborhood) of accident Briefly describe how the injury occurredWas the injury caused by defect in property? Yes No Has appropriate building inspector been contacted (if applicable)? Yes No If so, name of Agency/phone # Were there any witnesses? Yes No The names and contact information of all witnesses PREMISES INFORMATIONOwner/Renter/Company Name(s) Address/phone number Were the premises a private residence, business, or other? Do you have any photos of the premises/dangerous condition in question? Yes No Name of property insurer Police or Claim Number Adjuster INJURIES:What parts of your body were injured?Did you go to the doctor/hospital immediately after the accident? Yes No Name/phone # of doctor or hospital How did you get there? If by ambulance, what company? Do you have any photographs of your injuries? Yes No Do you have medical insurance? Yes No Name of Medical Insurance Co Medical Insurer Contact Info ID/Policy Number Has a plastic surgeon evaluated your injuries? Yes No Name of doctor Phone number of doctor Has premises owner’s insurer offered to pay your medical expenses? Yes No MEDICAL TREATMENT PROVIDERS:Doctor #1 Is treatment concluded? Yes No Doctor #2 Is treatment concluded? Yes No Doctor #3 Is treatment concluded? Yes No EMPLOYMENT AND INCOME INFORMATIONEmployer Employer Address Employer Phone #Job Title Job Description/Type of Work Pay Rate Hours worked/week Physical demands of your work; what job tasks have given you problems since the accident?Have you missed time from work because of your injuries? Yes No If so, how many days/hours have you missed? PRIOR ACCIDENTS AND INJURIESHave you filed a prior claim relating to a premises accident? (List dates, place and injuries)Did you receive an award? Yes No Approximately how much did you receive? Any prior on the job injuries? (date, employer, and injury)Do you have any prior medical conditions, such as prior injuries, that might be aggravated or affected by the injuries suffered in this accident? Yes No If so please describe any and all prior injuries and conditionsLIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS Δ You must complete the form on the next page too, in order for Peterson Law Offices to legally represent you.