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:

20. His/ Her car information

Vehicle Year:

18. Address:

19. Telephone number

20. Driving license #

Mark:

21. His insurance company :

State:

Tag #

22. His policy number:

24.Location of any damage to involved vehicle

24. General narrative of accident (prepare diagram if necessary):

23. Approximate speed and direction of travel for each vehicle

25 Damage to other property at the accident scene

28. Signaling devices

27. Traffic controls

26. Visibility

31. Passengers in plaintiff's vehicle

30. Passengers in defendant's vehicle

29. Skid marks, gouge marks, etc.

34. Traffic charges (nature and disposition; specifically, was there a guilty plea?)

33.Investigation by police

32. Other eyewitnesses

37. Defendant's statements at the accident scene

36. Plaintiff's actions at the accident scene

35. Plaintiff's statement 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?