Augusta Personal Injury Form 706-722-3500

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Save your progress and complete this form later. (optional)

How did you hear about our firm? *

I contacted the Hawk Law Group trying reach: *

Contact Information

Mr. Mrs. Ms. Miss? *

Legal First Name *

Legal Last Name *

Nick Name

Street Address *

City *

State *

Zip Code *

Home Phone *

Mobile Phone *

Work Phone

You agree to receive SMS text messages from Hawk Law Group *

Yes

No

Email Address

How long have you lived in the Augusta area?

Date of Birth * +

Social Security Number *

Driver's License Number

State of Driver's License

Are you married? *

No	Yes (enter spouse info below)

Spouse First Name

Spouse Last Name

Spouse Street Address (if different than above)

City

State

Zip Code

Spouse Home Phone

Spouse Mobile Phone

Have you ever been in bankruptcy? *

No	Yes (enter detailed info) Yes (enter detailed info)

Next of Kin

Relationship

Legal First Name

Legal Last Name

Nick Name

Street Address

City

State

Zip Code

Home Phone

Mobile Phone

Work Phone

Email Address

Employer Information

Current employment status *

Employer

Supervisor's name

Street Address

Phone number

City

State

Zip Code

Position held

Weekly income

Accident Information

Accident Location (street or intersection) *

Date of accident * +

Did the at fault driver receive a citation? *

No	Yes (If so, what for?) Yes (If so, what for?)

Did you receive a citation? *

No	Yes (If so, what for?) Yes (If so, what for?)

Police department that was at the scene *

Officer(s) that was at the scene

Any witnesses? If so list any names, addresses and contact numbers you have *

Explain IN DETAIL how the accident occurred (Were you driving? Where were you sitting? How did it happen? What type of impact was it? Etc...) *

Pain and injuries you sustained due to THIS accident *

Upload an image or scan of the accident report

Please upload images of your car, the defendant's car, and the accident scene.

Please upload images of your injuries.

Defendant's (at fault) Information

Defendant's Name *

Defendant's Street Address *

Phone number

Defendant's City *

Defendant's State *

Defendant's Zip Code *

Defendant's (at fault) Insurance

Defendant's Insurance Company Name *

Adjuster's Name

Policy Number

Claim Number

Your Car Insurance

Your Car Insurance Company (UM) *

Policy Number (UM) *

Claim Number (UM)

Insurance Adjuster's Phone Number (UM)

Insurance Adjuster's Name (UM)

If you are NOT the owner of the vehicle that was in the accident, and the owner of the vehicle has car insurance list that below. Insurance Company:

3. Policy Number

3. Claim Number

3. Insurance Adjuster's Name

Insurance Adjuster's Name

Vehicle Information

If your vehicle (or the vehicle you were in) has been taken to a shop, then what is name of shop?

Shop phone number

Shop street address

City

State

Zip Code

Shop's estimated cost of repairs

Medical Treatment for This Accident

Transported via ambulance? *

No	Yes (ambulance company) Yes (ambulance company)

First date of treatment * +

1. Hospital/Facility *

Doctor's Name (physician who treated you)

Street Address (hospital 1)

Phone number

City (hospital 1)

State (hospital 1)

Zip Code (hospital 1)

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.) *

Have you completed treatment with this provider? *

No	Yes (date of completion) Yes (date of completion)

2. Primary Care Provider

Primary Care Doctor's Name

Street Address (PCP

Phone number

City (PCP)

State (PCP)

Zip Code (pcp)

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

3. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address (hospital/facility 3)

Phone number

City (hospital/facility 3)

State (hospital/facility 3)

Zip Code (hospital/facility 3)

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

4. Hospital/Facility (hospital/facility 4)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 4)

Phone number

City (hospital/facility 4)

State (hospital/facility 4)

Zip Code (hospital/facility 4)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

5. Hospital/Facility (hospital/facility 5)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 5)

Phone number

City (hospital/facility 5)

State (hospital/facility 5)

Zip Code (hospital/facility 5)

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

Health Insurance

Check all that you have or that you can use because of a family member: *

1. Health Insurance Company

1. Name of person on policy

1. Policy Holder

1. Group Number

1. Policy Number

1. Member Number

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

2. Health Insurance Company

2. Name of person on the policy

2. Policy Holder

2. Group Number

2. Policy Number

2. Member Number

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

Tricare or other military insurance company

Military Sponsor Number

Military Policy Holders Name

Branch

Rank

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

Medicare HIC #

Medicaid HIC #

Medicare Advantage #

Medicare ID #

Upload an image of your health insurance ID card (FRONT)

Upload an image of your health insurance ID card (BACK)

Prior Accidents and Injuries

Have you had any car accidents or injuries prior to the one you are here about today? *

Yes

No

If so how many?

Prior accident date (estimate if you don't know the exact date) +

Injuries from accident

Doctors seen for that accident

Prior accident date (estimate if you don't know exact date) +

Injuries from accident

Doctors seen for that accident

Prior accident date (estimate if you don't know the exact date) +

Injuries from accident

Doctors seen for that accident

This is acknowledgement that submitting this form does not in any way bind this firm to represent you. Until this matter is accepted by a member of the firm, we will not be able to undertake any representation. *

I Agree

Submitted Date:

Administration Items

6. Hospital/Facility (hospital/facility 6)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 6)

Phone number

City (hospital/facility 6)

State (hospital/facility 6)

Zip Code (hospital/facility 6)

Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)

Have you completed treatment with this provider?

No	Yes (date of completion) Yes (date of completion)

Administration Items

7. Hospital/Facility (hospital/facility 7)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 7)

Phone number

City (hospital/facility 7)

State (hospital/facility 7)

Zip Code (hospital/facility 7)

Administration Items

8. Hospital/Facility (hospital/facility 8)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 9)

Phone number

City (hospital/facility 9)

State (hospital/facility 9)

Zip Code (hospital/facility 9)

Administration Items

9. Hospital/Facility (hospital/facility 9)

Doctor's Name (physician who treated you)

Street Address (hospital/facility 5)

Phone number

City (hospital/facility 5)

State (hospital/facility 5)

Zip Code (hospital/facility 5)

The Hawk Law Group in general	Attorney Victor Hawk
Attorney Chace Hawk	Attorney Reid Sanders
Attorney Shawn Merzlak	Attorney Tianna Bias
Attorney Kip McAlister	Attorney Chase Duff
Other Other