Client Intake Car Accident | Phoenix Personal Injury Lawyer

Name *

First

Last

An Vehicle You

Email *

Cell Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth (Month, Day, Year) *

Date / Time of the Accident *

Date

Time

Describe How The Accident Took Place *

Did The Police Come To The Scene *

Yes
No

Do You Have An Incident Report *

Yes
No

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

If you have the police report or incident report, please upload it here.

Where Is The Vehicle You Were Driving Currently Located

If you were the driver of the vehicle where is your vehicle right now? If you were a passenger do you know where the vehicle is located?

Did You Take Photographs Of Your Vehicle *

Yes
No

Please Load The Photos OF YOUR Vehicle Here

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Only load Photos Of Your Vehicle or the vehicle you were a passenger in.

Did You Take Pictures Of The Other Vehicle(s) *

Yes
No

Please Submit Photos Of The Other Vehicle(s)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Were You Injured *

Yes
No

Have You Recieved Any Professional Medical Attention *

Yes
No

Have you been treated by any medical professionals since the crash?

Please Describe Your Injuries To The Best Of Your Ability *

I don’t expect you to know your exact condition, but I would like to have some idea of what you believe your injuries are and where they are located.

Have You Filed A Claim With The Other Person's Insurance Company *

Yes
No

Have You Filed A Claim For This Accident With Your Insurance Company *

Yes
No
Not Sure

Please Put The Claim Information For The Other Driver Here

The name of the insurance company, the name of the adjuster, the claim number, and the phone number if you have it.

Please Upload Any Pictures Of Your Injuries Here

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Please Provide An Emergency Contact *

Who can I contact if I have not heard from you in two weeks? List their name and their phone number.