Litigation Intake Form

Identity and Contact Information
Please answer completely. Sensitive data should only be collected and stored on a secure, access-controlled site.
Full Legal Name*
First Middle Last Suffix
Include your middle name and any suffix.
Aliases and/or Former Legal Names
List all aliases, maiden names, and other formal names previously used. Enter “None” if not applicable.
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Use only if your firm has approved collecting SSNs through this form.
Driver’s License Number*
Driver’s License State of Issuance*
Driver’s License Class*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
People Who Currently Live With You*
Full Name Relationship Age

List each person living in your household.
Prior Addresses During the Past 10 Years
Street Address City State ZIP Dates Lived There

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Family, Education, and Background
Are you currently married?*
- Yes
- No
Current Spouse Information*
Provide spouse’s full name, address, and date of marriage.
Have you ever been married previously?*
- Yes
- No
Previous Spouses*
Full Name Current Address Marriage Dates
Children
Full Name Age

List all children, whether from a prior marriage or otherwise.
Education History*
State the highest grade completed and list all certificates or degrees, including dates and institutions/locations.
Have you ever been arrested and/or convicted of a crime?*
- Yes
- No
Arrest or Conviction Details*
Date Charge Court Outcome
Have you ever been involved in another legal action as a plaintiff or defendant?*
- Yes
- No
Prior Legal Actions*
Case Name / Style Court Role Outcome / Verdict / Settlement

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Employment and Pre-Incident Information
Employment, Self-Employment, Businesses, and Occupations During the Past 10 Years
Employer / Business Address Supervisor Duties Dates Pay at Incident Current Pay

Include every employer, business, self-employment activity, and occupation through the present.
Did you consume alcohol, drugs, or medication within 48 hours before the incident?*
- Yes
- No
Substances Consumed*
Substance Amount Date / Time Place
Cell Phones Available to You on the Day of the Accident
Phone Number Carrier Device / Description Listed Owner
Activities During the 30 Minutes Before the Incident*
Describe what you were doing, including every telephone call made or received.

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Accident and Communications
Trip and Detailed Incident Description*
State where you were coming from, your destination, all occupants in your vehicle, and exactly how the incident occurred.
Did you speak with any other driver or passenger after the collision?*
- Yes
- No
Statements Made After the Collision*
Identify who spoke and describe in detail what each person said.
Did you speak with any insurance adjuster after the incident?*
- Yes
- No
Insurance Adjuster Communications*
Adjuster Name Company Date Phone / Email What Was Discussed
Cellular Telephone Number in the Vehicle at the Time of the Accident
Carrier for Cellular Telephone in the Vehicle

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Injuries, Prior Accidents, and Limitations
Have you ever been injured before or after this incident?*
- Yes
- No
Other Injury History*
Injury Date Where / How Sustained Claim Made? Against Whom
Have you had any other accidents before or after this incident that did not result in injury?*
- Yes
- No
Other Non-Injury Accidents*
Date Type of Accident Location Brief Description
Activities You Can No Longer Perform
Identify each activity you could perform before the incident but can no longer perform because of the accident injuries. Describe the limitation.
Have you missed work because of the accident injuries?*
- Yes
- No
Lost Work Details*
Date(s) Days / Hours Lost Paid During Absence? Reason Paid Amount Paid
Before or after this accident, have you suffered a similar injury or medical condition?*
- Yes
- No
Similar Injury or Medical Condition Details*
Describe the condition, dates, treatment, and whether it existed before or arose after this accident.

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Gyms, Pharmacies, and Medical Treatment
Have you belonged to a gym or exercise facility during the past 3 years?*
- Yes
- No
Gym or Exercise Facility Memberships*
Facility Name Address Membership Start Membership End
Pharmacies Used During the Past 10 Years
Pharmacy Name Address Telephone Number Approximate Dates Used
All Medical Treatment During the Past 10 Years*
Provider / Facility Address / City Telephone Treatment Type Condition / Reason Dates of Treatment

Include hospitalizations, urgent care, emergency room visits, primary care, specialists, therapy, chiropractic care, imaging, and other treatment.
Additional Information
Provide any other information that may help the litigation team evaluate or prepare your case.
Email
This field is for validation purposes and should be left unchanged.

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Employer / Business	Address	Supervisor	Duties	Dates	Pay at Incident	Current Pay

Date(s)	Days / Hours Lost	Paid During Absence?	Reason Paid	Amount Paid

Provider / Facility	Address / City	Telephone	Treatment Type	Condition / Reason	Dates of Treatment

Full Name	Relationship	Age

Street Address	City	State	ZIP	Dates Lived There

Full Name	Current Address	Marriage Dates

Full Name	Age

Identity and Contact Information