Intake Evaluation Form

The attorneys at Layman Law Firm ask their prospective clients to do the best they can in completing the required fields on this intake form.

Do not feel overwhelmed by the process. We will have a productive first meeting even if you are not sure of all the information. However, it is very helpful to have all the relevant information available to us from the beginning, as it will allow us to start the process sooner. Please feel free to call our office if you have any questions.

Step 1.) Fill out the form below (Click here for the printable version that can be filled out and brought in).

Step 2.) If you have not yet, call the office to schedule an appointment with an attorney for the first consultation.

*Indicates a Required Field

Intake Evaluation Form

Date of Accident: *

Today's Date: *

How Did You Hear About Us*
OnlineFriend/FamilyAdvertisementOther

Background Information

Full Name: *

Other names known by (alias and maiden names):

Email Address: *

Street Address: *

City: *

State: *

ZipCode: *

Home Phone (Main): *

Office Phone:

Other/Cell:

Date of Birth: *

Social Security Number:

Place of Birth:

Age:

Weight:

Height:

Driver's License No. (Including State):

Marital Status (Check One)
MarriedSingleDivorcedSeparatedWidowed/Widower

Spouse's Name:

Former Spouses:
YesNo

If yes, list names, addresses, phone numbers and dates of marriage and divorce:

Children and/or other licensed household drivers (if not child, state relationship):

Name/Age

Occupation

Occupation/Employer:

Employer Address:

Job Title:

How long employed:

Name of Supervisor:

Supervisor Telephone:

Last date worked before illness/injury:

Rate of pay ($):

How often:
MonthlySemi-MonthlyBimonthlyWeekly

Date returned to work:

Did your job duties change after illness/injury?
YesNo

If yes, please indicate how:

Do you have income tax records for the last 5 years documenting your earnings for those years?:
YesNo

Incident Information

Date of Accident:

Time:

SOL:

Location:

County:

City:

Weather Conditions:

Status: (eg., driver, passenger, pedestrian, guest, customer, etc.); If passenger, who is driver?

Were police called?
YesNo

Agency (City Police, County Sheriff, State Trooper):

Was fire department called?
YesNo

Was ambulance called?
YesNo

Were you taken to the hospital via ambulance?
YesNo

Do you have a copy of the accident/incident report?
YesNo

List any citations and to whom:

Describe what happened:

Operation/Available Seatbelts?
YesNo

Seatbelts in use?
YesNo

Did you sign any papers for any insurance companies or give any verbal
or written statements to any insurance companies?
YesNo

If yes, please state to whom given:

Were any statements made by the other parties accepting fault for the accident?
YesNo
If yes, state the content of the statement and to whom it was made:

Your Automobile Insurance Information

Name of your automobile insurance company:

Address:

Policyholder/Insured (If not you):

Policy Number:

Claim number:

Adjuster's Name:

Phone Number:

Policy Limits:

PIP application completed?
YesNo

If you were either driving or a passenger in a vehicle not owned by you, please answer the following:

Name of vehicle owner:

Address of vehicle owner:

Vehicle owner's automobile insurance company:

Address of owner's automobile insurance company:

Telephone Number:

Policy number:

Claim Number:

Adjuster's Name:

Description of Vehicle Involved in Crash

Vehicle (Year/Make/Model):

Plate Number:

Describe damage to your vehicle:

Location of your vehicle:

Property damaged resolved?
YesNo

Do you have a copy of the repair estimate?
YesNo

Were photographs taken?
YesNo

If so, by whom?

Please state location of damaged vehicle:

Have you reported the crash to the insurance company?
YesNo

Workers' Compensation

Were you on the job at the time of the accident?
YesNo

Workers' Compensation carrier:

Address:

Insured:

Claim Number:

Adjuster's Name:

Phone Number:

Are you collecting any Worker's Compensation benefits because of your injuries related to this accident?
YesNo

Health Insurance Information

Please list information on ALL health insurance policies available to you from the date of the
accident until today, including group or individual, Medicare, Medicaid (all companies from
which you get Medicaid benefits) and all supplemental health insurance policies covering you. If you have been covered (since the date of the accident) by more than three health insurance
companies, please use the back of this form to write the additional information.

If you have had no health insurance coverage (from the date of the accident until today), please put "none" on Health Insurance Company 1.
If you have Medicaid, please put WHY you qualify for this and list all Medicaid companies that you collect benefits from such as Florida Medicaid, Wellcare, Staywell, Medi Pass, Healthease, Amerigroup, United Health Care of Florida, etc. We need copies of all of the insurance cards from all of the companies you collect Medicaid benefits from.
If you have Medicare AND ARE NOT 65 YEARS OLD, please put WHY you qualify for this.

PLEASE PROVIDE US WITH A COPY OF ALL HEALTH INSURANCE CARDS. If you can't make copies, please bring the cards to our office so that photo copies can be made for our file.

Health Insurance Company 1:

Address:

Policyholder:

ID/Policy Number:

If Group Plan, employer of policyholder:

Health Insurance Company 2:

Address:

Policyholder:

ID/Policy Number:

If Group Plan, employer of policyholder:

Health Insurance Company 3:

Address:

Policyholder:

ID/Policy Number:

If Group Plan, employer of policyholder:

Disability

Are you on Social Security Disability?
YesNo

If yes, do you get monthly benefits?
YesNo

At-Fault Party Information

Name:

Address:

Driver's License No. (include State):

Vehicle:

Plate Number:

Insurance Company:

Adjuster's Name:

Policy Number:

Claim Number:

Policy Limits:

Recorded statement given?
YesNo

Was there more than one at-fault party? If so, list immediately below

Name:

Address:

Driver's License No. (include State):

Vehicle:

Plate Number:

Insurance Company:

Adjuster's Name:

Policy Number:

Claim Number:

Policy Limits:

Recorded statement given?
YesNo

Witness Information

Names of any witnesses: (Please include addresses and telephone numbers, if known.

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Injuries/Medical Treatment

List all PAIN and SYMPTOMS you have felt from this accident (from your head to your toes):

Have you sustained any visible bruises and/or scarring as a result of the accident?
YesNo

List ALL health care providers you have treated with for this accident including ambulance, hospital, treating doctors, family doctors, chiropractors, neurologists, orthopedists, MRI testing, physical therapy, massage therapy, CT scans, X-rays, etc.

Were you transported by ambulance?
YesNo

Name of Ambulance Company:
Name of hospital where you were initially treated:

Have you had any additional visits to any hospital for ER treatment or for outpatient testing?
YesNo

Dates:

In sequential order, if possible, list all other health care providers you have treated with for this accident:

When are your next doctors' appointments?

Dr. Name:

Date:

Dr. Name:

Date:

Prior Injuries and Medical Treatment

Describe in detail each and every PAST injury, accident, including work-related accidents, in which you have ever been involved. (Include date, time, location, type of accident, and injuries.) even if you sustained no injury and/ or made no claim.

Motor Vehicle Accidents:

Slip and fall/trip and fall accidents:

Injuries that occur on the job:

School and/or sport-related injuries:

Other injuries or complaints:

Name and address of family physician and/or primary care physician:

Have you ever complained to or treated with any of the following PRIOR TO this accident?

Chiropractor:
YesNo

If yes, with whom?

MRI Facility:
YesNo

If yes, with whom?

Orthopaedist:
YesNo

If yes, with whom?

Other:

List every surgery you have had to date:

Additional Background Information

List every claim or lawsuit in which you have been involved in any way. Include approximate year, parties involved, reasons and results.

Have you ever been arrested?YesNo

Date(s):

Charge(s):

Have you ever been convicted of a crime?
YesNo

Date(s):

Charge(s):

Result(s) (fine, penalty, probation, confinement, etc.):

Do you currently have a bankruptcy case pending?
YesNo

If yes, please list the name and address of your bankruptcy attorney.

Have you ever filed bankruptcy?
YesNo

Date:

Location:

PLEASE NOTE THAT THE FILING OF BANKRUPTCY DURING THE PENDENCY OF YOUR ACCIDENT CLAIM MAY ADVERSELY AFFECT YOUR CASE!

Have you ever been represented by any other attorney for any reason?
YesNo

Name

Address:

Reason:

Give the names, addresses and telephone numbers of two people who will always know where to reach you:

Name

Address:

Phone:

Name

Address:

Phone:

Please leave this field empty.

Call For A Free Legal Consultation

(321) 773-2111

*Indicates a Required Field

Intake Evaluation Form

Background Information

Occupation

Incident Information

Your Automobile Insurance Information

Description of Vehicle Involved in Crash

Workers' Compensation

Health Insurance Information

Disability

At-Fault Party Information

Witness Information

Injuries/Medical Treatment

Prior Injuries and Medical Treatment

Additional Background Information