Funding Intake Form

Name

Phone:

Email:

SS#:

Date Of Birth:

Any Prior Funding – From Whom:

How Much: / What Date:

Were you Referred by:

Name of Firm and Attorney:

Date of Accident:

Current Physician:

How Many Accidents in the Last 5 Years:

Any other Personal Injury cases Pending:

Are You Still Treating from your current personal Injury Case:

If so with whom:

Any Surgery Epidurals: / MRI:

What are your Injuries:

Any Pre-Existing conditions:

Did you have Insurance at the time of the accident:

Name of your Insurance company and Claim Number:

Did you have any passages in your Car:

Were they Injured also:

Do you have an uninsured motorist:

Did you go to the hospital or doctor immediately after the accident:

Did you go by Ambulance:

Did the police go to the scene of the accident:

Do you have a copy of the police report:

Description of the accident:

Did the accident happen while you were working:

Did the Fault party have insurance:

With what company:

Was a citation issued and Who got the citation issued:

Were you working before the accident:

Company Name:

Did you lose any income and how much:

Do you have a criminal record:

Are you paying alimony:

Date Received: