PLEASE TELL US ABOUT YOUR ACCIDENT
Date of Accident
MM slash DD slash YYYY
Time of Accident

: Hours

Minutes

AM/PM
Date Employer Notified
MM slash DD slash YYYY
Person Notified
Accident Location
Street Address City State / Province / Region ZIP / Postal Code Country
Accident Description
Do you know of any witnesses to accident, or persons with knowledge of accident?
- Yes
- No
If so, please list below:
Name
Phone Number
Name
Phone Number
Name
Phone Number
PLEASE TELL US ABOUT YOUR ACCIDENT INJURIES
Injuries You Received
Did you go to the ER / hospital?
If yes, which hospital?
Were you taken by ambulance?
If no, how did you get there?
PLEASE TELL US ABOUT THE HOSPITALS/CLINICS WHERE YOU WERE TREATED
Hospital/Clinic
Date(s)
Hospital/Clinic
Date(s)
Hospital/Clinic
Date(s)

LIST THE DOCTORS WHO YOU HAVE SEEN IN THE ORDER YOU SAW THEM
Physician #1:
Dates Seen
Injury
Physician #2:
Dates Seen
Injury
Physician #3:
Dates Seen
Injury
Physician #4:
Dates Seen
Injury
Physician #5:
Dates Seen
Injury
HAS ANY DOCTOR GIVEN YOU A DISABILITY RATING?
Rating Physician
MMI Date
MM slash DD slash YYYY
Rating
Rated Injury
Rating Physician
MMI Date
MM slash DD slash YYYY
Rating
Rated Injury
WHO IS YOUR FAMILY PHYSICIAN?
Name
Phone Number
Address
Street Address City State / Province / Region ZIP / Postal Code Country
How long has he/she been your family physician?
INJURIES/ACCIDENTS YOU HAVE HAD BEFORE YOUR ACCIDENT?
Have you had ANY injuries prior to this accident that required medical attention? Please tell us:
Date
MM slash DD slash YYYY
Types of injuries
Legal action taken?
Date
MM slash DD slash YYYY
Types of injuries
Legal action taken?
Date
MM slash DD slash YYYY
Types of injuries
Legal action taken?

PLEASE TELL US ABOUT ANY DIFFICULTIES YOU ARE HAVING
PLEASE TELL US ABOUT ANY DIFFICULTIES YOU ARE HAVING
IF YOU HAVE BEEN PREVIOUSLY REPRESENTED BY AN ATTORNEY FOR THIS ACCIDENT, PLEASE TELL US
Attorney Name
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
ON THE DIAGRAM, PLEASE CIRCLE OR PLACE AN X ON THE PART(S) OF YOUR BODY THAT WAS INJURED
Download this image and upload to "Upload Here" below:
Upload Here
Max. file size: 1 MB.
FOR OFFICE USE ONLY
Intake Date
MM slash DD slash YYYY
Statute of Limitations
MM slash DD slash YYYY
Notes

There’s Never a Fee Unless We Get Money For You

CALL (904) 777-JOHN

Orange Park
1063 Park Avenue
Orange Park, FL 32073
(904) 215-5555

Palatka
1303 Reid Street
Palatka, FL 32177
(386) 325-5555

Middleburg
2554 Blanding Blvd
Suite L Middleburg, FL 32068
(904) 406-5555

Starke
964 Temple Avenue
Starke, FL 32091
(904) 964-5555

Keystone Heights
6679 Shands Rd.,
Keystone Heights, FL 32656
(352) 335-5555

Gainesville
111 SE 1 Ave Suite 140
Gainesville, FL 32601
(352) 777-5646

Ocala
The Concord Building
7 E Silver Springs Blvd Suite 102
Ocala, FL 34470
(386) 777-5646

Social Security Disability Form