Personal Injury Intake - Law Office of Henrik Mosesi

Personal injury intake form & retainer agreement

Please be as complete as possible so that we can start your claim right away. If you do not feel comfortable providing your Social Security Number, leave it blank and call our office after you submit this form and provide it to us over the phone.

After you complete the intake, you will be redirected to another page to complete and sign the contingency retainer agreement and authorizations.

Your Name *

First

Last

Your Street Address:

City:

State:

Zip Code:

Cell Number:

Other Phone:

Your Date of Birth:

Your Age:

Your Driver's License No:

Your Driver's License State:

Restrictions on License?

Your Gender:

Where Were You Seated?

Your Social Security No.:

Any Previous Accidents or Injuries?

Please give date(s) and details of body parts injured.

Are You Married?

If so, please provide your spouse's name, address, date of birth and contact information. Your spouse may have a claim for damages for "loss of consortium" as a result of your accident. If you decline to state, please explain above.

Child Seat Information:

Under California law insurance companies must replace a child care seat after a crash regardless if the child seat was occupied or not. Please provide the make, model and what you paid for your child car seat(s).

Date of Accident:

Time of Accident:

Location of Incident

How Many Passengers in Your Car?

Nearest Cross-Street:

Street You Were On and Direction of Travel:

i.e. Headed East on Glenoaks

City:

Traffic Control Device:

i.e. Traffic light, stop sign.

Road Condition:

i.e. Wet, dry, etc.

Weather:

i.e. Clear, rain, cloudy, sunny, etc.

Nature of Your Trip:

Where were you going?

Which Lane Were You In:

Lanes are number from left to right.

What Street Was the Other Party On:

Passengers in Other Car?

If yes, how many?

Other Party Direction of Travel:

What Lane Was Other Party In?

How Did the Accident Happen?

Your Car Make:

Your Car Year:

Your Car Color:

How Many Doors?

Your License Plate No.:

Who is the Registered Owner of Your Car? *

First

Last

Registered Owner's Address:

Disregard if same as you.

Location of the Vehicle Now:

If at a body shop, please give name, address and phone number.

Any Prior Damage on Your Car?

Please describe.

Your Employer's Name:

If you are claiming lost wages.

Your Employer's Address:

If you are claiming lost wages.

Your Job Details:

If you are claiming lost wages.

How Much Time Lost from Work?

How Much Wages Lost from Work?

Your Auto Insurance Carrier:

Your Claim Number:

Your Policy Number:

Your Adjuster's Name:

Your Coverage Amount:

Your Health Insurance Carrier:

Your Health Insurance Policy No:

Did You Use Your Health Insurance for This Accident?

IMPORTANT. If you used your health insurance for treatment after the accident, we will have to notify your health insurance when your case is settled. They will have a reimbursement claim against your settlement. Please email us your Health Insurance Card.

Did You Medi-Cal for This Accident?

IMPORTANT. If you used your Medi-Cal for treatment after the accident, we will have to notify the California Department of Health Care Services when your case is settled. By law, they have a reimbursement claim against your settlement. Please email us your Medi-Cal Card.

Did You Medicare for This Accident?

IMPORTANT. If you used your Medicare for treatment after the accident, we will have to notify Medicare when your case is settled. By law, they have a reimbursement claim against your settlement. Please email us your Medicare Card.

Did You Medicare Advantage for This Accident?

IMPORTANT. If you used your Medicare Advantage for treatment after the accident, we will have to notify Medicare when your case is settled. By law, they have a reimbursement claim against your settlement. Please email us your Medicare Advantage Card.

Did Ambulance Arrive on Scene?

IMPORTANT. If they did, you will receive a bill. Please forward the bill to our office.

Did Paramedics Arrive?

IMPORTANT. If they did, you will receive a bill. Please forward the bill to our office.

Did Police Arive?

Which Police Department?

Police Report No.:

Briefly Describe Your Injuries:

Please describe in detail which body part was injured, the severity of the pain from 0-10, how often do you feel the pain, etc.

Any Property Damage?

Please describe if any personal property was damaged in the accident like a phone, shoes, clothing, eye glasses, etc. Please provide receipts, proof of purchase, value, etc.

Your Family Doctor:

First

Last

Your Doctor's Address:

Your Doctor's Phone No.:

Other Driver:

First

Last

Other Driver Address:

Other Driver City:

Other Driver State:

Other Driver Zip:

Other Driver Phone No.:

Other Driver Driver's License No.:

Other Driver Driver's License State:

Other Driver Date of Birth:

Other Driver Make of Car:

Other Driver Year of Car:

Other Car Color:

Other Car How Many Doors?

Was Other Car Towed?

Yes
No
I Don't Know

Where Was the Damage to the Other Car?

Describe in detail the damage to the other car that hit you. Please provide us with all pictures of the accident scene.

Other Driver's Insurance Carrier:

If known.

Other Driver's Insurance Adjuster Name:

If known.

Other Driver's Insurance Policy No.:

If known.

Other Driver's Insurance Claim No.:

If known.

Other Driver's Insurance Phone No.:

If known.

Passenger #1 Information

First

Last

Passenger #1 Address:

Passenger #1 Phone No.:

Passenger #1 Date of Birth:

Passenger #1 Email:

Passenger #1 Social Security No.:

Passenger #1 Gender:

Male
Female

Passenger #1 Previous Accidents?

If yes, please give date and location.

Passenger #1 Previous Injuries?

If yes, please give detail of previous injuries involving the same body parts as now.

Passenger #1 Family Doctor Name/Address:

Passenger #1 Family Doctor Phone:

Passenger #1 Time Lost from Work?

If yes, please state how many hours or days and the amount you have lost. Please provide proof to us.

Passenger #2:

First

Last

Passenger # 2 Address:

Passnger #2 Phone No.:

Passnger #2 Date of Birth:

Passnger #2 Email:

Passenger #2 Social Security No.:

Passenger #2 Gender:

Male
Female

Passenger #2 Previous Accidents?

If yes, please give date and location.

Passenger #2 Previous Injuries?

If yes, please give detail of previous injuries involving the same body parts as now.

Passenger #2 Family Doctor Name/Address:

Passenger #2 Family Doctor Phone:

Passenger #2 Time Lost from Work?

If yes, please state how many hours or days and the amount you have lost. Please provide proof to us.

Witness Name:

First

Last

Witness Address:

Witness Phone No.:

Witness 2 Name:

First

Last

Witness 2 Address:

Witness 2 Phone No.: