Sexton Lawfirm

GENERAL INFORMATION

Full Name (required):

Present Address:

Street 1 (required):

Street 2:

City (required):

State (required): Zip (required):

Home Phone:

Cell Phone:

Your Email (required):

Family: (List immediate family members)

Marital Status:  Single Married

AUTOMOBILE INSURANCE COVERAGE ON YOU

Was there Automobile insurance on the car that you were riding in at the time of the collision?
 Yes No

Who owned the car that you were riding in at the time of the incident?

What is the name of the insurance company that provided automobile insurance on the car that you were in at the time of the incident?

How much insurance coverage was there on the car you were riding in?

Was there any uninsured/underinsured coverage on the vehicle you were riding in?
 Yes No

If it was not your car, how much underinsured/uninsured coverage do you have on your vehicle?

Do you have any medical payments coverage on your insurance policy or was there any on the vehicle in which you were riding?
 Yes No

Automobile insurance that covered you personally at the time of the collision:
Do you have any auto insurance?

 Yes No

How much?

HEALTH INSURANCE INFORMATION FOR YOU

At the time of your injuries, were you covered by any health insurance policies?
 Yes No

Is your health insurance provided through your employer or your spouse's employer?
 Your Employer Your Spouse's Employer

Have you filed any of your medical bills that incurred as a result of this incident with this health insurance company?
 Yes No

WRONGDOER'S (DEFENDANT'S) AUTOMOBILE INSURANCE

If the wrongdoer had insurance, what is the name of that insurance company?

What are the policy limits, if you know?

YOUR WORK BACKGROUND The amount of the recovery in this case will be affected by your loss of earnings and earning capacity, so please outline carefully your work background.

Were you employed at the time of the incident?
 Yes No

What was your rate of pay?

Were you paid by the  hour week month?

Have you missed any time from work as a result of your injuries?
 Yes No

If so, list the inclusive dates that you were unable to work as a result of your injuries:
From: To:

Have you before this incident lost time from work due to an injury? If so, give dates and details.

Did you lose wages for the period of time missed from work?
 Yes No

If yes, state the total loss to date and the dates covered

THE INCIDENT

Date of the Incident:

Location of Incident (as to intersection or fixed objects):

In your own words, give a description of the incident, including direction parties were traveling:

Did the defendant admit that he or she caused the incident?
 Yes No

Were you and others injured wearing a seat belt?
 Yes No

YOUR PERSONAL INJURIES

Were you injured as a result of the incident?
 Yes No

Were you taken by ambulance to the hospital?
 Yes No

What specific parts of your body were injured and what were your injuries as a result of this incident?
Please be specific and describe your injuries.

Did you experience pain and suffering due to your physical injuries? (Pain and suffering includes mental suffering, but mental suffering is not a legal item of damage unless there is physical suffering also. Anxiety, shock, and worry are examples of what might be included under mental pain and suffering.)
 Yes No

If yes, be specific and describe your pain and suffering.

Had you ever had a previous injury to this specific part of your body?
 Yes No

Please state your present physical condition and any complaints due to the incident, including anything that you cannot do or do with difficulty as compared with before the incident, specify injuries from the incident, and present complaints.

PROPERTY DAMAGE TO YOUR CAR

Was your car damaged?
 Yes No

If so, what parts and areas of your car?

Who owned the car that you were riding in?

Was the car totaled?
 Yes No

If you wish a consultation other than about an auto accident, please describe your case in detail below: