Client Intake — Kwame Thompson P.C.

Client Information

Full Name *

Date of Birth

Spouse's Full Name (if married)

Social Security #

Address

Home Phone

Cell Phone

Work Phone

Email (Home)

Email (Work)

Driver's License #

Were you the Driver or Passenger?

Emergency Contact Name

Emergency Contact Phone

Accident / Incident Information

Date of Incident *

Time of Incident

City of Incident

County of Incident

Road / Intersection

Were police called?

Yes No

Was an accident report filed?

Yes No

Report Number (if known)

Injuries & Treatment

Describe all injuries, aches, and discomforts *

Did you go to the hospital?

Yes No

Hospital Name

Transported by ambulance?

Yes No

X-rays taken?

Yes No

Ambulance Service Name

Seen a doctor since the accident (other than ER)?

Yes No

Treating Doctors (name, address, phone)

Loss of Earnings

Employer

Your Position / Title

Rate of Pay

Hours per week

Do you have health insurance?

Yes No

Insurance Carrier Name

Type (PPO / HMO / Medicaid / Other)

Property Damage (Your Vehicle)

Is your vehicle drivable?

Yes No

Estimated Damage ($)

Your Vehicle (Year, Make, Model, Color)

License Plate #

Your Auto Insurance Carrier

Policy Number

Claim Number (if known)

Other Driver / Defendant Information

Other Driver's Name

Other Driver's Phone

Other Driver's Address

Other Driver's Insurance Carrier

Their Policy / Claim Number

Other Vehicle (Year, Make, Model)

Other Vehicle Plate #

Witnesses

Were there independent witnesses?

Yes No

Witness Names, Phone Numbers, and Addresses

Have you given a recorded statement to anyone?

Yes No

If yes — to whom and when?

Prior Accidents or Incidents

Please describe any prior accidents or incidents (if none, write "None")

By submitting this form you consent to The Law Office of Kwame Thompson P.C. collecting and processing your information for the purpose of evaluating your legal claim. This form does not create an attorney-client relationship.

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Questions? Call us at (404) 994-5948.