Personal injury initial client interview checklist

PERSONAL INJURY INITIAL CLIENT INTERVIEW CHECKLIST 1. Name 2. Address

3. CLAIM # 4. Insurance company of the liable party: 5. Adjuster:

Telephone of Adjuster: 6. Date of accident: 7. Time of accident: 8. Date of birth 9. Social Security number 10. Marital status and family 11. Employment (employer, title and job responsibilities)

12. Salary: 13. Location of accident 14. Time of accident 15. Weather conditions 16. Physical description of accident scene (including pertinent landmarks):

17. Name of the other driver: 18. Address: 19. Telephone number 20. Driving license # 20. His/ Her car information Vehicle Year: Mark: Tag # State: 21. His insurance company : 22. His policy number: 23. Approximate speed and direction of travel for each vehicle 24. General narrative of accident (prepare diagram if necessary): 24.Location of any damage to involved vehicle 25 Damage to other property at the accident scene 26. Visibility 27. Traffic controls 28. Signaling devices 29. Skid marks, gouge marks, etc.

30. Passengers in defendant's vehicle 31. Passengers in plaintiff's vehicle 32. Other eyewitnesses 33.Investigation by police 34. Traffic charges (nature and disposition; specifically, was there a guilty plea?)

35. Plaintiff's statement at the accident scene 36. Plaintiff's actions at the accident scene 37. Defendant's statements at the accident scene

38. Accident scene comments by investigation police officer 39. Post-accident communications by anyone, particularly party statements 40. Visible injuries to plaintiff 41. Photographs 42. Other evidence 43. Pre-accident activities of the defendant 44. Use of alcohol or other intoxicants 45. Prior driving record 46. General health and eyesight 47. Restrictions on operator's permit 48. Evidence of intoxication by plaintiff or plaintiff's driver 49. Knowledge of plaintiff in the community 50. Observation of plaintiff post-accident 51. Familiarity with other witnesses 52. Defendant's destination prior to accident 53. Existence of written statement, recorded statement or transcribed traffic court testimony 54. Explanation of suit procedure 55. Do not discuss suit except with attorney 56. What car were you driving: 57. What is your insurance 58. Do have full coverage 59. Do you have health insurance 60. Company 61. Policy number 62. Did you make a claim 63. Claim No: 64. Did the police come on spot:

65. Were you taken to hospital?

66. Where 67. When were you discharged?

68. Are you seeing doctor?

69. Name of Doctor 70. Address of doctor 71. Did the doctor tell you to take rest form work 72. How long?