Website Personal Injury Info Form 706-722-3500

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

How did you hear about our firm?

Contact Information

Legal First Name *

Legal Last Name *

Nick Name

Street Address *

City *

State *

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

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

Accident Information

Accident Location (street or intersection) *

Date of accident * +

Day of Accident: *

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

Zip Code

Shop's estimated cost of repairs

Employer Information

Current employment status *

Employer

Supervisor's name

Street Address

Phone number

City

State

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 *

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

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

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

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

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

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

Zip Code

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

2. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone number

City

State

Zip Code

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

3. Hospital/Facility

Doctor's Name (physician who treated you)

Street Address

Phone number

City

State

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: *

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

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