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Website Personal Injury Info Form 706-722-3500
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How did you hear about our firm?
Contact Information
Legal First Name
*
Legal Last Name
*
Nick Name
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Home Phone
*
Mobile Phone
*
Work Phone
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Are you married?
*
No
Yes (enter spouse info below)
Spouse First Name
Spouse Last Name
Spouse Street Address (if different than above)
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Home Phone
Mobile Phone
Work Phone
Email Address
Accident Information
Accident Location (street or intersection)
*
Date of accident
*
+
Day of Accident:
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time 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 accident report
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Shop's estimated cost of repairs
Employer Information
Current employment status
*
Employed
Not Employed
Disability
Retired
Other
Other
Employer
Supervisor's name
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Position held
Weekly income
Prior Accidents and Injuries
Have you had a prior accident?
*
Yes
No
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 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
Defendant's (at fault) Information
Defendant's Name
*
Street Address
*
Phone number
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Defendant's (at fault) Insurance
Defendant's Insurance Company Name
*
Adjuster's Name
Policy Number
Claim Number
Medical Treatment for This Accident
Transported via ambulance?
*
No
Yes (ambulance company)
Yes (ambulance company)
1. Hospital/Facility
*
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
*
Have you completed treatment with this provider?
*
No
Yes (date of completion)
Yes (date of completion)
2. Hospital/Facility
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
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
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Have you completed treatment with this provider?
No
Yes (date of completion)
Yes (date of completion)
5. Hospital/Facility
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
Have you completed treatment with this provider?
No
Yes (date of completion)
Yes (date of completion)
Future Medical Treatment
Have you completed your medical treatment?
*
Yes
No
1. Hospital/Facility
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
2. Hospital/Facility
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
3. Hospital/Facility
Doctor's Name (physician who treated you)
Street Address
Phone number
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Treatment (ER, Orthopedics, Surgery, Chiropractic, etc.)
Health Insurance
Check all that you have or that you can use because of a family member:
*
None
Medicaid
Medicare
Private/Group
Other
Other
1. Insurance Company
Name of person on policy
Policy Holder
Group Number
Policy Number
Member Number
Upload an image of your health insurance ID card (FRONT)
Upload an image of your health insurance ID card (BACK)
2. Insurance Company
Name of person on policy
Policy Holder
Group Number
Policy Number
Member Number
Upload an image of your health insurance ID card (FRONT)
Upload an image of your health insurance ID card (BACK)
Your Car Insurance
Your Car Insurance Company
*
Policy Number
*
Claim Number
Insurance Adjuster's Phone Number
Insurance Adjuster's Name
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:
Policy Number
Claim Number
Insurance Adjuster's Phone Number
Insurance Adjuster's Name
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
Enter the word in the image
*
Submitted Date: