1Personal Information

2Referral & Accident

3Incident Details

4Emergency Contact & Family

5Employer Information

6Machine/Device

7Motor Vehicle Accident

8Loss of Wages

9Your Auto Insurance

10Documents & Signature

Personal Information

Name(Required)

First Last

DOB

Address

Street Address City State ZIP Code

Cell

Home

Do you send & receive text messages?

Yes

Email Address(Required)

Date of Injury

Social Security

Driver License

Referral & Accident

How were you referred to our office?

Professional Referral

Client Referral

Name of Referral

Source

Walk-in

Unknown

Internet

Billboard

Fox 11

News 4

Channel 2

Accident Type

Motor Vehicle Accident

Slip and Fall

Dog Bite

Vehicle & Pedestrian

Product/Premises Liability

Other

Other, Explain

Description of Accident

Location of Accident (City/State)

Incident Details

Were authorities called?

Yes

Were you transported by ambulance?

Yes

Did you go to the hospital?

Yes

Witnesses Name

Witness Phone

Was a Police Report taken?

Yes

Do you have a copy of the police report?

Yes

Emergency Contact & Family

Emergency Contact

Relationship

Emergency Contact Address

Street Address City State ZIP Code

Emergency Contact Phone

Marital Status

Single

Married

Divorced

Widowed

Do you have children?

Yes

Employer Information

Employer Name

Job Title

Employer Address

Street Address City State ZIP Code

Employer Phone Number

If injured by a Machine/Device

Type of Product

Name of the Manufacturer

Do you have any pictures of the machine or device you were hurt by?

Yes

If Motor Vehicle Accident

Defendant's Auto Insurance Company Name

Claim

Policy

Name of Driver

Name of Passenger

Name of Adjuster

Adjuster Phone

Adjuster Fax

What are the injuries that you sustained in the accident?

Do you have any prior injuries?

Yes

If so, what are they?

Do you have any prior claims with any other attorney as the result of an accident where you are or have received compensation?

Yes

Do you have any prior lawsuits with any other attorney as the result of an accident where you are or have received compensation?

Yes

Loss of Wages

Are you currently working?

Yes

List anything that you cannot do because of the accident

List anything that you can do but because of the pain you just cannot do as well as before the accident

List and loss of life enjoyment

Do you have any prior injuries? (Loss of Wages section)

Yes

If yes, what are they?

Your Auto Insurance

Your Auto Insurance Company Name

Claim

Policy

Name of Driver

Name of Passenger

Name of Adjuster

Adjuster Phone

Adjuster Fax

Does the claimant carry UM, UIM, Med Pay on the policy?

Yes

What type? (UM/UIM/Med Pay)

Policy Limit $

Police Report Filed?

Yes

Name of Police Department

Report #

Was the at-fault driver cited for the accident?

Yes

Were pictures taken of the injuries?

Yes

If yes, who took the pictures?

Date the pictures were taken

What body parts did Claimant injure?

How did the accident occur? (Include city/state/street of accident location)

Where did you receive treatment and by what doctor?

Because of the result of this accident have you had any wage loss?

Yes

If yes, what dates?

IMPORTANT DOCUMENTS NEEDED FOR YOUR CONSULTATION:

If you have any documents, pictures, reports or anything else you believe is important to your case, we will make copies at this appointment and your originals will be returned before you leave today.

Signature (type your full legal name)(Required)

Date

Consent

I agree to receive text messages from Herb Santos, Jr Law Firm at the number provided about my inquiry, including consultation scheduling, appointment reminders, document requests, and case status updates. Messages may be sent using automated technology.

Consent

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Consent

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FREE CONSULTATION

Personal Injury Intake Form

Personal Information

Referral & Accident

Incident Details

Emergency Contact & Family

Employer Information

If injured by a Machine/Device

If Motor Vehicle Accident

Loss of Wages

Your Auto Insurance

IMPORTANT DOCUMENTS NEEDED FOR YOUR CONSULTATION: