Law Offices of Eric P. Oren, Inc.

Personal Injury - Questionnaire

Note: This questionnaire is submitted for review by the Law Offices of Eric P. Oren, Inc. (hereinafter referred to as ATTORNEY) The submission of information is for review only. The attorney does not represent you in your legal matter unless and until a formal written Retainer Agreement is signed by both you and the attorney. No decision or guarantee has yet been made on whether the attorney will accept your case. Further additional information may be requested in order for the attorney to reach a decision. Please note that it takes time to review the material submitted and to make any reply or decision. The Law Offices of Eric P. Oren, Inc. will attempt to respond in writing to your request for representation as soon as possible. Please allow 5 days for our office to respond to your request prior to calling our office to followup on your request for representation.

Background Information

If Claim Arises from an Auto Accident, Fill Out sections 1 - 18 and Sections 31-37

1. 1. Were you the passenger in the subject accident?
2. 2. Did you have auto insurance at the time of the subject accident?
3. 3. Name of your auto insurance carrier at the time of the subject accdient:
4. 4. Do you have auto insurance medical pay coverage?
   
   
   Amount: $
5. 5. Do you have Health Insurance?
6. 6. If medical bills have been paid, how have they been paid?
7. 7. Have you received medical treatment on a lien basis?
   Yes
   No
   Not Sure
8. 8. Names and ages of other passengers in the vehicle which you occupied:
9. 9. Location of Accident:
10. 10. Were the Police Notified:
    
    
    Which Police Dept.?
11. 11. Was a Traffic Collision Report prepared?
12. 12. Were photos taken of vehicle damage/injuries?
13. 13. Witnesses Names & Address:
14. 14. Please give a description of how the accident occured:
15. 15. Person responsible for the accident:
    
    
    Name:
    
    
    Insurance carrier:
    
    
    Claim Number:
16. 16. Registered Owner of Vehicle (if different from driver):
17. 17. Describe your injuries:
18. 18.List all the medical providers where you have received treatment:
    
    
    Provider:
    
    
    Address:
    
    
    Telephone No.:
    
    
    Provider:
    
    
    Address:
    
    
    Phone:
    
    
    Provider:
    
    
    Address:
    
    
    Phone:
19. 
    

    If Claim is a Non-Auto Accident Case, Fill Out Sections 19-37

    19. Date of Accident:
20. 20. Location of Accident:
21. 21. Did you report the accident?
22. 22. If you reported the accident who did you report it to?
23. 23. Witness Names & Addresses:
24. 24. Have you spoken to anyone from the insurance company:
25. 25. Name of Insurance Company:
26. 26. Claim No.:
27. 27. List all the medical providers from whom you have received medical treatment as a result of this accident:
    
    
    Provider:
    
    
    Address:
    
    
    Telephone No.:
    
    
    Provider:
    
    
    Address:
    
    
    Phone:
    
    
    Provider:
    
    
    Address:
    
    
    Phone:
28. 28. Who do you think is responsible for your accident and why do you think they are responsible?
29. 29. Please give description of how the accident occurred:
30. 30. Injuries (Please Describe):
31. 
    

    Wage Loss Information

    31. Have you lost time from work because of the subject accident?
32. 32. If you have lost time from work, please state how much time you have missed and your rate of pay:
    
    
    Amount of Time Missed:
33. 
    

    Medical Treatment Received

    33. Were you transported by ambulance to the Hospital?
34. 34. Date of first medical treatment following the accident:
35. 35. Activities unable to do since accident:
36. 36. Prior accidents and injuries:
37. 37. Other Attorneys Consulted:
    
    
    If Yes, Name of Attorney: