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?