Car Accidents — Initial injury lawyer meeting — Interview Questionnaire

Some personal injury lawyers will gather most of the information that they need during a face-to-face meeting. Others may give you a written questionnaire to fill out. Just as when talking to your lawyer, it is important to be completely candid when filling out a questionnaire for your personal injury lawyer.

If your personal injury lawyer uses a questionnaire it may include some or all of the questions in the sample provided here. This sample may seem long and complicated, but the answers can be important to your case.

General Background Information

1. Name _______________________________________________________
2. Age _______________________________________________________
3. Have you ever been known by any other names? If so, please list. _______________________________________________________
4. If you are a minor, provide your parent or guardian’s full name, his or her relationship to you, address and telephone number. _______________________________________________________
5. Social Security number _______________________________________________________
6. Marital status _______________________________________________________
7. Name of spouse _______________________________________________________
8. Age of spouse _______________________________________________________
9. Home address _______________________________________________________
10. Home address of spouse _______________________________________________________
11. Work address _______________________________________________________
12. Work address of spouse _______________________________________________________
13. Home telephone no. _______________________________________________________
14. Home telephone no. of spouse _______________________________________________________
15. Work telephone and fax no. _______________________________________________________
16. Work telephone and fax no. of spouse _______________________________________________________
17. Email address and any other addresses or telephone numbers where you or your spouse may be contacted? _______________________________________________________
18. List all other persons living in your household, their ages, relationship to you and whether they depend on you for support. _______________________________________________________
19. List any other persons who depend on you for their support; include ages, relationship to you and addresses. _______________________________________________________
20. Have you signed any authorizations to release information or any other documents in connection with the accident/incident? _______________________________________________________
21. If so,
(a) do you have a copy of the document? _______________________________________________________
(b) do you know the title and purpose of the document? _______________________________________________________
(c) at whose request did you sign the document? _______________________________________________________
(d) when did you sign the document? _______________________________________________________
22. List every arrest, charge and conviction ever brought against you by the police or state, or determined by a court.
Date _______________________________________________________
Place of Arrest _______________________________________________________
Charges _______________________________________________________
Result _______________________________________________________
23. Have you ever been in the military service? _______________________________________________________
24. If so, what branch? _______________________________________________________
25. Please state dates of service and type of discharge. _______________________________________________________
26. Did you receive any commendations or medals? If so, which ones? _______________________________________________________

27. Did you have any service disability or injuries? If so, give the details. _______________________________________________________

Employment Background

1. Are you presently employed? If so, state the name, address and telephone number of your employer and how long you have worked there.
_______________________________________________________
_______________________________________________________
_______________________________________________________

2. What is your present job title? _______________________________________________________
3. What are your job duties? (Be specific and complete.)
_______________________________________________________
_______________________________________________________
_______________________________________________________

4. What is your rate of pay? _______________________________________________________
5. How many hours per week do you work? _______________________________________________________
6. Were you employed at the time of the accident/incident? If so, state the name and address of your employer.
_______________________________________________________
_______________________________________________________
_______________________________________________________

7. What was your job title? _______________________________________________________
8. What were your job duties? (Be specific and complete.)
_______________________________________________________
_______________________________________________________
_______________________________________________________

9. What was your rate of pay? (Include any “non-monetary” pay, such as the use of a car.) _______________________________________________________

10. Were you a member of any union? ___ If so, indicate the union local chapter, and list all union benefits which were available to you (e.g., vacation policy, insurance benefits, guaranteed pay increases).
_______________________________________________________
_______________________________________________________
_______________________________________________________

11. How many hours per week were you working on a regular basis prior to the accident? _______________________________________________________
12. Did the accident occur while you were working for your employer? _______________________________________________________
13. Did the accident occur while you were at the workplace? _______________________________________________________
14. Did the accident occur on your way to or from the workplace? _______________________________________________________

15. Were any co-workers, involved? If so, give their names and addresses. _______________________________________________________

16. Were there any witnesses to the accident/incident? If so, give their names and addresses.
_______________________________________________________
_______________________________________________________
_______________________________________________________

17. Have you been able to perform the same job duties listed in number 8 above since the accident/incident? If not, explain.
_______________________________________________________
_______________________________________________________
_______________________________________________________

18. Did you report the accident/incident to your employer? If so, list: the date and time of the report
(a) whether the report was oral or written
(b) the name of the person to whom you reported the accident/incident, and
(c) if in written or recorded form, whether you have retained a copy.
_______________________________________________________
_______________________________________________________
_______________________________________________________

19. Have you given an oral or written statement to your employer or to someone acting on your employer’s behalf (for example, an insurance adjuster)? If so, to whom did you give the statement and what do you recall stating? _______________________________________________________

20. Have you missed any time from work as a result of any injuries incurred from the accident/incident? If so, list all dates you were unable to work.
_______________________________________________________
_______________________________________________________
_______________________________________________________

21.Were you paid by your employer for the dates you were unable to work? _______________________________________________________

22. Have you made a claim for any insurance benefits, workers’ compensation benefits, or any other benefits as a result of the accident/incident? _____ If so, identify all documents you signed to obtain such benefits and indicate whether you have a copy of each.
_______________________________________________________
_______________________________________________________
_______________________________________________________

23. Have you received any insurance benefits, workers’ compensation benefits, or any other benefits as a result of the accident/incident?___ If so, from whom? _______________________________________________________
24. Have you lost any wages for the time periods missed from work as a result of the accident/incident? If so, list the total amount of wages lost. _______________________________________________________

25. Have you had to change jobs, or change job duties, as a result of the accident/incident? If so, explain in detail how your job or job duties have changed and the reason for each change.
_______________________________________________________
_______________________________________________________
_______________________________________________________

26. If you have changed jobs or job duties since the accident/incident, have you had any change in earnings? If so, explain in detail.
_______________________________________________________
_______________________________________________________
_______________________________________________________

27. List your complete employment record for as far back as possible. (This is important to show occupational disability.)
Employer’s name/address
_______________________________________________________
_______________________________________________________
_______________________________________________________
Dates of employment
_______________________________________________________
_______________________________________________________
_______________________________________________________
Reason for leaving
_______________________________________________________
_______________________________________________________
_______________________________________________________
28. How much money did you make in the year preceding the accident/ incident?
_______________________________________________________
_______________________________________________________
_______________________________________________________
29. Did you file federal and state income tax returns for the last three years? _______ If so, where were they filed? _______________________________________________________
Were they joint returns? _______________________________________________________
30. Did you retain copies of them? _______________________________________________________
31. Did you retain payroll stubs? _______________________________________________________
32. Are the figures shown on the income tax returns and the payroll stubs the same? _____ If not, explain.
_______________________________________________________
_______________________________________________________
_______________________________________________________

33. Did you have any income from any source that you did not declare? If so, explain.
_______________________________________________________
_______________________________________________________
_______________________________________________________

Physical History

1. List every physical or mental examination you have had during the last ten years. For each exam, list the name and. address of the doctor, the date of the examination, and any results as best as you can recall.
(a) Date _______________________________________________________
Place of examination Doctor’s name _______________________________________________________
Reason for examination _______________________________________________________
Result of examination _______________________________________________________

(b) Date _______________________________________________________
Place of examination _______________________________________________________
Doctor’s name _______________________________________________________
Reason for examination _______________________________________________________
Result of examination _______________________________________________________

(c) Date _______________________________________________________
Place of examination _______________________________________________________
Doctor’s name _______________________________________________________
Reason for examination _______________________________________________________
Result of examination _______________________________________________________

2. List all prior accidents and injuries you have had and specify whether they resulted in claims for damages. For each accident or injury, complete the following:
(a) Date _______________________________________________________
Place of injury _______________________________________________________
Nature of injury _______________________________________________________
Extent of injury _______________________________________________________
Damage claim _______________________________________________________
Amount received and from whom _______________________________________________________

(b) Date _______________________________________________________
Place of injury _______________________________________________________
Nature of injury _______________________________________________________
Extent of injury _______________________________________________________
Damage claim _______________________________________________________
Amount received and from whom _______________________________________________________

(c) Date _______________________________________________________
Place of injury _______________________________________________________
Nature of injury _______________________________________________________
Extent of injury _______________________________________________________
Damage claim _______________________________________________________
Amount received and from whom _______________________________________________________

3. List all illnesses, disabilities and diseases you had before your car accident. (This is relevant to the issue of present physical complaints.) For each one specify the following information:
(a) Date _______________________________________________________
Nature of illness, disability or disease _______________________________________________________

Treating physician _______________________________________________________
Duration of illness, disability or disease _______________________________________________________

Manifestations of illness, disability or disease _______________________________________________________

(b) Date _______________________________________________________
Nature of illness, disability or disease _______________________________________________________

Treating physician _______________________________________________________
Duration of illness, disability or disease _______________________________________________________

Manifestations of illness, disability or disease _______________________________________________________

4. List all illnesses, disabilities and diseases you had or have had after your car accident:
(a) Date _______________________________________________________
Nature of illness, disability or disease _______________________________________________________

Treating physician _______________________________________________________
Duration of illness, disability or disease _______________________________________________________

Manifestations of illness, disability or disease _______________________________________________________

(b) Date _______________________________________________________
Nature of illness, disability or disease _______________________________________________________

Treating physician _______________________________________________________
Duration of illness, disability or disease _______________________________________________________

Manifestations of illness, disability or disease _______________________________________________________

5. List all activities which you have not been able to perform since the car accident, or those which you can now perform only with difficulty (e.g., household chores, sports activities, social activities).
_______________________________________________________
_______________________________________________________
_______________________________________________________

6. List the name, address, and telephone number of each physician, psychiatrist or other medical care provider who has examined, treated or interviewed you relating to your current injuries, and for each one complete the following:
(a) Physician’s name _______________________________________________________
Address _______________________________________________________
Telephone number _______________________________________________________
Date of treatment _______________________________________________________
Treatment prescribed _______________________________________________________
Costs incurred _______________________________________________________
(b) Physician’s name _______________________________________________________
Address _______________________________________________________
Telephone number _______________________________________________________
Date of treatment _______________________________________________________
Treatment prescribed _______________________________________________________
Costs incurred _______________________________________________________
(c) Physician’s name _______________________________________________________
Address _______________________________________________________
Telephone number _______________________________________________________
Date of treatment _______________________________________________________
Treatment prescribed _______________________________________________________
Costs incurred _______________________________________________________
7. List every prior claim or prior lawsuit you have brought for personal injury or property damage either before or after the accident and for each one complete the following:
(a) Claim _______________________________________________________
Date _______________________________________________________
Attorney _______________________________________________________
Defendant(s) _______________________________________________________
Resolved by suit _______________________________________________________
Resolved by settlement _______________________________________________________
Result _______________________________________________________
(b) Claim _______________________________________________________
Date _______________________________________________________
Defendant(s) _______________________________________________________
Attorney _______________________________________________________
Resolved by suit _______________________________________________________
Resolved by settlement _______________________________________________________
Result _______________________________________________________
(c) Claim _______________________________________________________
Date _______________________________________________________
Defendant(s) _______________________________________________________
Attorney _______________________________________________________
Resolved by suit _______________________________________________________
Resolved by settlement _______________________________________________________
Result _______________________________________________________
8. Are you receiving, or have you at any time received, any payments for military service related injury or disabilities? _______ If so, give the details, your VA claim number, and the present status of your service-connected injury or disability.
_______________________________________________________
_______________________________________________________
_______________________________________________________

Miscellaneous

1. List all drugs and other medications prescribed for you as a result of the injuries you received. Explain whether you purchased the drugs or medications and where you purchased each.
_______________________________________________________
_______________________________________________________
_______________________________________________________
2. List all medical support items prescribed (e.g., braces, neck supports, traction devices, oxygen units, clothing, crutches, glasses, dentures), their total cost, and where they were purchased.
_______________________________________________________
_______________________________________________________
_______________________________________________________
3. Have you had to hire any domestic help as a result of your accident? _____ If so, list the name and address of all domestic help hired, the dates and amount paid, and describe the type of assistance you required.
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. List all your lost earnings as a result of the accident. _______________________________________________________
5. Have you ever been found to be permanently or partially disabled by any state, federal, or administrative agency as a result of the accident? If so, when did this occur and what were the details of the decision? _______________________________________________________
6. Please list any additional information you have that is not covered in this interview form but which you believe may be of any assistance to us in preparing and evaluating your case. _______________________________________________________

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