Fall Down Personal Injury Fact Sheet

Fall Down Personal Injury Fact Sheet

KENNETH A.VERCAMMEN
ATTORNEY AT LAW
732-572-0500
FALL DOWN PERSONAL INJURY FACT SHEET

Please fill out completely and return

Todays date:

1. Plaintiff name:
Address:
Phone cell:
Phone work:
Phone home:
Email
Date of Birth: mm/dd/yyyy
Social Security #:
Spouse:

2. Date of Accident:
Town, County, State:
Day of Week Accident Occurred:
Time:
Weather:
Ground Conditions:
Where Coming From & Going To:
The Dangerous Conditions that Caused the Fall:
Parts of the body hitting the ground:
Skid Marks by Any Car:
Alcoholic beverages or Medication within 12 hours before accident?

3. Description of Accident:

4. Hospitals
Address
Date of Admission
Date of Discharge

5. Diagnostic Tests: (X-Ray, MRI)
Taken By:
Address:
Date:
Results:

6. Doctor Name:
Address:
Phone:
Date of Treatment:
Date of Reports:

7. Medical Provider Name:
Address:
Phone:
Date of Treatment:
Date of Reports:

8. Still Being Treated?
Medical Provider Name:
Nature of Treatment:

9. Aggravation of Prior Injuries by Accident:
Prior Doctor:

10. Employer Name
Address:
Job/Position:
Gross/Week:
Net/Week:
Time Lost:
Total Wages Lost:

11. IF RETURN TO WORK:
Current Employer Name:
Address:
Job:
Gross/Week:
Net/Week:

12. Other Loss of Income, Earnings:

13: Medical Bills:
Doctor:
Amount Unpaid:
Amount Paid:
Hospital Bills:
Medicine, etc.:
Total Medicals (As of ________ [date]):

14. Plaintiffs Private Major Medical:
Address:
Phone:
Policy Number:

15. Other Out of Pocket Expenses and Other Losses:
Major Medical Card:
Hospital Bills:
Hospital Records:
Medical Bills & Records:
Repair damage Estimate:

16. Defendant Name:
Address:
Other Defendants:
Address:

17. Eye Witness Name:
Address:
Phone:

18. Officers of Investigating Police Department:
What did you tell the police?

19. Names of Insurance Agents and other individuals you discussed the case with:
What did you say:

20. If you claim that the defendant made any admissions as to the subject matter of this lawsuit, state: ;
(a) the date made
(b) the name of the person by whom made;
(c) the name and address of the person to whom made;
(d) where made;
(e) the name and address of each person present at the time the admission was made;
(f) the contents of the admission;
(g) if in writing, attach a copy.

21. If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state:
(a) the date of the communication;
(b) the name and address of each participant;
(c) the name and address of each person present at the time of such communication;
(d) where such communication took place; and
(e) a summary of what was said by each party participating in the communication.

22. Violation by Defendant oflaw (i.e. or other statute)
Negligent Actions by Defendant:
23. Have you ever been indicted and convicted of a crime? (this question required by Rules of Court)
24. Prior accidents involving injury in which you received an insurance settlement or suit was started? (including workers compensation)
25. Prior car accidents with only property damage?
26. Are you receiving Medicare/Medicaid?
27. Are you receiving SSI?

Is there anything else important?
Documents to be supplied to attorney & in his possession:	- Please prepare a diagram of the accident site - Police Report - Declaration Sheet - Medical/Hospital Bills and Records - Photographs of Accident Site - Photographs of Injuries, Scars, Cuts