PREMISES LIABILITY CLIENT INTAKE FORM

Premises Liability Client Intake Form

PREMISES CLIENT INTAKE FORM
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First Name*

Last Name*

Address

City

US States

Zip

DATE OF BIRTH*

SOCIAL SECURITY NUMBER*

Phone Number*

EMERGENCY CONTACT NUMBER*

DATE OF INJURY*

WHERE WERE YOU HURT?*

HOW WHERE YOU HURT*

NAME OF THE EMPLOYEE/MANAGER/OWNER YOU NOTIFIED*

DID YOU FILL OUT AN INCIDENT REPORT? (IF YES, PLEASE SEND IT TO US)*

DID YOU GO TO THE HOSPITAL? IF SO, WHERE & HOW?*

WHAT INSURANCE COMPANY HAS CONTACTED YOU? (NAME & PHONE NUMBER)*

HAVE YOU GIVEN A STATEMENT TO ANY INSURANCE COMPANY?*

YOUR HEALTH INSURANCE COMPANY (IF NONE, PUT N/A)*

WHAT ARE YOUR INJURIES?*

WHERE DID YOU RECEIVE MEDICAL TREATMENT?*

WHERE ARE YOU CURRENTLY TREATING?*

DO YOU NEED A MEDICAL RECOMMENDATION?

HAVE YOU SUFFERED AN INJURY IN A PRIOR ACCIDENT?*

PLEASE LIST ANY PRIOR INJURIES OR SURGERIES IN THE PAST 10 YEARS*

Phone

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Premises Liability Client Intake Form