Intake Information Form — Cumberlege Law

Your Name

First NameMiddle NameLast Name

How were you referred?

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Home Telephone

Please enter a valid phone number.Format: (000) 000-0000.

Cellphone (if different from home number)

Please enter a valid phone number.Format: (000) 000-0000.

E-mail

example@example.com

Date of Birth

Date

Social Security Number (we keep this confidential)

Emergency Contact Name

First NameMiddle NameLast Name

Emergency Contact Telephone Number

Please enter a valid phone number.Format: (000) 000-0000.

Marital Status

Spouse's Name

First NameMiddle NameLast Name

Spouse's Telephone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Incident

Date

Time of Incident

Hour Minutes

AM/PM Option

Location of Incident

Please provide a detailed description of the incident location

Country

Description of Incident

At the time of the incident, which field below bests describes you:

Were you wearing a seatbelt?

Did the airbags deploy?

Were you on the job?

Is there any reason to think at-fault party was working for a governmental entity?

Did the Police Respond?

Police Department

Case Number

Were there any Witnesses?

Witness Names and Phone Numbers

Vehicle Owner Name (If different than you)

First NameLast Name

Vehicle Owner Contact Phone (If different than you)

Please enter a valid phone number.Format: (000) 000-0000.

License Plate Number

Vehicle Year

Vehicle Make

Vehicle Model

Insurance Company

Policy Number

Adjuster Name

First NameMiddle NameLast Name

Adjuster Phone

Please enter a valid phone number.Format: (000) 000-0000.

Claim Number

Do you have Medical Payments Coverage?

Medical Payments Coverage Limits

Usually between $5,000 to $25,000

Do you have Underinsured / Uninsured Motorist Coverage?

Underinsured / Uninsured Motorist Coverage Limits

Are there any resident relatives with additional coverage? A resident relative is usually defined as someone related to you by blood, marriage, or adoption and lives with you in the same household.

Resident Relatives Name / Policy Information

Are there any other household vehicles, RVs, boats, or motorcycles?

Other Household Vehicles / RVs / Boats / Motorcycles Name / Policy Information

Vehicle Year

Vehicle Make

Vehicle Model

License Plate Number

Insurance Company

Policy Number

Adjuster Name

Adjuster Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Claim Number

Do you have Medical Payments Coverage?

Medical Payments Coverage Limits

Do you have Underinsured / Uninsured Motorist Coverage?

Underinsured / Uninsured Motorist Coverage Limits

Any other household vehicles, RVs, boats, or motorcycles?

Name / Policy Information for Other Household Vehicles, RVs, Boats, or Motorcycles

At-Fault Driver Name

First NameMiddle NameLast Name

At Fault Vehicle Owner Name (if different than driver)

First NameLast Name

Vehicle Year / Make / Model

At-Fault Insurance Company

Claim Number (if you do not have a claim number, please provide the polocy number)

Adjuster Name

First NameLast Name

Adjuster Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Adjuster Email

example@example.com

Please describe your accident injuries

Primary care provider

Treatment providers for accident-related medical care

PLEASE BE AS THOROUGH AS YOU CAN BE IN LISTING ALL PROVIDERS

Were you transported by ambulance?

Ambulance provider

Were you seen in the emergency room?

Are you currently still treating for accident injuries?

Have you ever been involved in another accident?

When was the other accident?

Where did the other accident occur?

Have you previously injured the same body parts injured in this collision?

When were the same body parts previously injured?

Where did the prior injury occur?

Medical providers involved in the prior injury

Have you had any workers' compensation claims?

When was the workers' compensation claim?

Where was the workers' compensation claim filed?

Is a government entity involved?

Which government entity?

Is this also a workers' compensation case?

Employer

Have you missed any work due to the incident?

How much work have you missed?

Position / Wage

Do you have health insurance?

Health insurance company name

Health insurance policy number or member ID

Health insurance contact information

Do you have Medicare?

Medicare ID number

Do you have Medicaid?

Medicaid ID number

Please use this space to tell me anything about your incident and claim that was not covered above

Case Information Form

Section 1: Case Information Form

Section 2: Incident Information

Section 3: Insurance Information for the Vehicle You Were In

Section 4: Your Insurance Information (Only If Different Than The Vehicle You Were In)

Section 5: At Fault Party Information

Section 6: Your Accident Injuries and Medical Treatment

Section 7: Additional Information

Section 8: Additional Information - Government

Section 9: Employment

Section 10: Health Insurance