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 StatusSSNName/adress/phone number of next to kinHave 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 accidentBriefly 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 witnessesPREMISES INFORMATIONOwner/Renter/Company Name(s)Address/phone numberWere 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 insurerPolice or Claim NumberAdjusterINJURIES: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 hospitalHow 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 CoMedical Insurer Contact InfoID/Policy NumberHas a plastic surgeon evaluated your injuries? Yes No Name of doctorPhone number of doctorHas premises owner’s insurer offered to pay your medical expenses? Yes No MEDICAL TREATMENT PROVIDERS:Doctor #1Is treatment concluded? Yes No Doctor #2Is treatment concluded? Yes No Doctor #3Is treatment concluded? Yes No EMPLOYMENT AND INCOME INFORMATIONEmployerEmployer AddressEmployer Phone #Job TitleJob Description/Type of WorkPay RateHours worked/weekPhysical 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.
