Client Intake Form is basically used to get the preliminary case information of the client. These Forms are generally used for specific cases such as for personal injury, family law, criminal law, etc. This form is beneficial for clients to recollect the exact happenings and information, without forgetting them. The Intake form also helps the attorney to probe with probing questions, once the Form is filled up by the client.
You can use Intake forms for the following:
Client Intake Form – Auto Accident contents:
The specific and valuable information about the injured client is very important for the attorney in preparing the law case of the client. The accurate information is essential because, such lawsuits involves settlement award running to millions of dollars.
You can prepare your own Client Intake Form – Auto Accident, by using below given template to get the detailed and exact accident detail from the client:
Client Intake Form – Auto Accident
Date Today:
Client’s Name_____________________
Address:________________________________
________________________________________
Street________________________
City__________________________
State_________________________
Zip___________________________
Telephone: (H)_____________________(W)________________(C)
Date of Birth:___________________________ Place of Birth:____________________SSN:_________
Martial Status:___________________________ Dependents:___________________________Owe Child Support? …. Yes ….. No
Closest Relative (spouse) (Name):___________________
Address/telephone:___________________________________
_____________________________________________________
Occupation:___________________________ Weekly Gross:______________________Length of Employment:
Employer’s Name:___________________________
Employer’s Address:__________________________
__________________________________________
Describe Job Duties:___________________________
Accident Information for Client
Name\address of Driver:_________________________
Name\address of Owner:_________________________
Vehicle: Year: ____________ Make:_____________ Model:_____________
Color:___________ Registration:_____________
Insurer and policy No.:_______________________
Does Client Own the Car: ….. Yes ….. No Rent: ….. Yes …. No Lease: ….. Yes …. No
Does client live in a household with a family member who owned and insured a car on the date of accident: ….. Yes ….. No………. . …….. If yes, please list:
Does client have collision insurance: ….. Yes ….. No……..
Is client filing a property damage claim: …. Yes …. No………
If yes, against which company:
Date of Incident: ________________ , Day: ___________, Time: ………
Seatbelt: …. Yes …. No Airbag deployed: …. Yes ….. No Wipers: …. Yes …. No
Lights: …. Yes ….. No……….
Location: Town/city:____________________
Name of Officer and Agency that responded if any:_________________________
Citations Issued: … Yes …. No
If Yes, to Who and Why:
Describe Damage to car:
Estimate to Repair Vehicle: $
Repaired: …. Yes ….. No Estimate: …. Yes ….. No B Broken glass: ….. Yes ….. No
Car towed: …. Yes …. No Photos: …. Yes ….. No
What happened (in as much detail as possible):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Name/address/telephone of Occupants in Client’s Vehicle:_____________
Name/address/telephone of Witnesses:___________________________
Defendant’s Information__________________
Name\address of Driver:__________________________
Name\address of Owner:___________________________
Vehicle:_____________, Year:________ , Make:_______ , Model:__________
Color: Registration:__________________________
Insurer and Policy No.:_______________________
Does Defendant own the car: …. Yes …. No …. Not Sure Rental Company:
Does Defendant live in a household with a family member who owned and insured a car on the date of accident:…. Yes …. No
Damage to car:……………….., Repaired: …. Yes …… No
Estimate: Yes No………….., Broken glass: Yes No…… Car towed: Yes No
Photos: Yes No
Medical Information
Ambulance on scene: Yes…. No…. What company?:
At the time of the accident, was there any blood: Yes…. No….
What parts of client’s body are injured:
When did client first go to hospital:
What hospital:
How did s/he get there:
What was done: examination: ….. x-rays: …… other:
Other doctors visited, the addresses and dates:
Medical payments (physicians, medications, health care providers, special equipment,etc.):
Lost wages:
Time out:
Other loss:
How pain & injury limits activities:
Other symptoms: (irritability, nausea, headache, stress, inability to move body parts, insomnia, etc.):
Physical condition prior to accident:
Prior physical problems:
Family physician/health care provider (name, address, telephone number):
Additional Information
Is client on: ….. Medicare …… Medicade ……. Worker’s Compensation ….. Social
Security ….. Disability Insurance …… Ηealth Insurance
Please note, these agencies place liens on your file which may make your case more difficult to settle and which will have to be repaid.
Previous claims/lawsuits/auto-accidents/injuries/worker’s comp claims: ….. Yes ….. No
If yes, explain:
Draw diagram of accident: