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  Kenneth Vercammen was the Middlesex County Bar Municipal Court Attorney of the Year

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Since 1985, KENNETH VERCAMMEN has worked as a personal injury attorney, working for injury victims and their families. By taking a hard-hitting, aggressive approach toward the insurance companies, KENNETH VERCAMMEN and our co-counsel have consistently obtained outstanding results for many injured clients over the years I am proud to have worked on cases in various capacities, small and large. While obviously prior results cannot guarantee the outcome of future cases, I can guarantee that you case will receive the same degree of dedication and hard work that went into each of these prior cases. In direct contrast to the hard-hitting approach we take toward the insurance companies is the soft approach we take toward our clients. I am proud of my compassionate staff as I am of the outstanding financial results they have achieved. For many years, I have watched them treat our clients with patience, dignity and respect. I would have it no other way. Many years ago, I attended a seminar sponsored by the American Bar Association on Law Practice Management. This was to help insure that each of our clients is always treated like a person -- not a file! We recognize that you are innocent victims and that you have placed your trust in us. Please understand that we understand what you are going through. Feel comforted that we are here to help you. If you retain KENNETH VERCAMMEN to represent you, we will give you the same advice we give each of our clients -- concentrate on your life, you family and your health. We will take care of everything else. Leave all of the work and worry about your legal rights to us. Trust us. Believe in us. Have faith in us as your attorneys. Understand that we will always to do what we believe is best for you and your case. Helping you is our job. In fact, it is our only job -- guiding injury victims like you through one of the most difficult times of your lives, with care and concern -- while fighting aggressively to the limits of the law to obtain compensation and justice for each of you!