• Title: Mr. Mrs. Ms. Miss. Dr.
• Name: *
• Address:
• City: *
• Postal Code:
• Phone: *
• E-mail Address:
• Age:
• Referred by:
• Parties Involved:
• When did your injury occur? (Notice of claim must be provided to the Defendant within 120 days of the incident; to own insurer within 7 days)
  
• How was the injury caused? Provide as much detail as you can. Include your view with respect to who is at fault.
• What is the nature of your injuries?
  Be as detailed as possible.
  
• Have you returned to work? Yes No
• If so, when?
• What kind of work do you do?
  
• What is your annual income? $
• What continuing problems are you experiencing?
  
• Have you applied for accident benefits?
  For other benefits?
  
• What accident benefits have you received to date?
  What other benefits have you received to date?
  
• What is the shortfall there between your income and benefits paid?
  
• What is your insurer's name?
  
• What evidence do you have of your income from all sources for the year preceding the incident?
  
• What medical reports do you have? In the event that we agree to represent you we will require every medical report obtained as a result of this incident.
  
• Can you provide a list of the names, addresses and telephone numbers of all hospitals, doctors, etc., who have treated you as a result of this incident?
  
• Do you have a police report? Yes No
• If a death was involved and an autopsy performed, provide the date and place of the autopsy and the name, address and telephone number of the doctor who performed the autopsy.
  
• Were you referred to a specific lawyer?
• Additional Comments