Injury Questionaire

PERSONAL INJURY QUESTIONNAIRE

Name:
E-Mail Address:
Home Address:

Home Phone:
Type of Employment:
Work Phone:
Marital Status:
Your Private Health Insurance Company:
Your Automobile Insurance Company (if applicable):

Name of Negligent Party or Company:
Negligent Party's Automobile Insurance Company (if applicable):

Date of Accident:
Time of Accident:
Place of Accident:
Investigated By:

Describe in your own words how the accident happened:


State who was injured and describe what injuries were caused by the accident and how the injuries have progressed:


Describe what medical treatment has taken place and where:


Total medical expenses to date:	$
Total time lost from work to date:
Total cost of property damage:	$
Total transportation costs, car rental, etc. to date:	$
Total cost of any other loses to date:	$
Please describe the other losses:

James L. Burns
24441 Detroit Road, Suite 300, Westlake, Ohio 44145
Phone: (440) 575-1100 -- Fax: (440) 871-5182
Email info@jameslburns.com