Murray & Damschen, P.C. - Client Data Sheet (Auto Injury Case)
We provide this list of questions on our website, so you will can print the page and bring the information with you to our office. The information is needed from you in connection with our representation of you regarding your case. This confidential information is requested within the scope of our attorney-client relationship and will remain confidential unless we determine it is necessary to disclose the information during our representation of you.
It is especially important that we know about: (1) ALL previous accidents or injuries of any kind, (2) ANY previous claims for injuries and lawsuits, and (3) Your COMPLETE medical background, especially regarding the areas of your body that may be involved in your case. Please provide complete answers.
CLIENT NAME: ____________________
Address: _______________________________________________________
Telephone Numbers
Home: ______________Work:______________ Cell: ______________
Social Security Number:____________ Date of Birth:______________
Where do you presently work (business name and address):
_________________________________________________________________________________
How did you hear about Murray & Damschen P.C.?
_________________________________________________________________________________
SPOUSE'S NAME & ADDRESS :
_________________________________________________________________________________
Date and place of Marriage: ________________
Spouse's Employer's Name & Address:
________________________________________________________________________________
Telephone Numbers
Home:______________ Work:______________ Cell: ______________
LIST ALL CHILDREN OF CLIENT (indicate whether natural, adopted or dependent step-children). Attach extra pages if needed:
(A) Name & Address: ______________________________________________________________
Telephone Numbers
Home: ______________Work:______________ Cell:______________
Date and place of Birth: ____________________________________________________________
(B) Name & Address: ______________________________________________________________
Telephone Numbers
Home: ________________ Work:______________ Cell:______________
Date and place of Birth: ____________________________________________________________
(C) Name & Address: ______________________________________________________________
Telephone Numbers
Home: ______________Work: ______________ Cell:______________
Date and place of Birth: ___________________________________________________________
EDUCATION
(A) High School Grad? Yes No Year: _____
(B) Name of College Attended: _______________________________________________________
Degree Achieved: _______________Year:______
(C) Name of College Attended: _______________________________________________________
Degree Achieved: _______________Year:______
CRIMINALHISTORY
It is a law in Colorado that if a person has been convicted of a felony, or a crime of dishonesty (such as theft or forgery) that fact may be used in the trial. The defense will conduct an investigation into your medical, employment, legal and criminal background. We must be prepared in advance to respond to any of this kind of evidence.
Have you ever been convicted of a felony? yes no
Have you ever been convicted of forgery or theft? yes no
Have you ever been charged with a serious crime? yes no
Do you have any outstanding warrants? yes no
Have you ever been arrested? yes no
Has your driver's license ever been suspended or revoked? yes no
If you answered "Yes" to any of the above questions, please provide an additional page explaining the conviction, charge, warrants and/or arrests in detail, setting forth the dates, the specific charge and the facts surrounding the incident.
ACCIDENT INJURY INFORMATION
Date of accident: _________ Time of accident:___________
Location (street, city and county): ____________________________________________________
Weather conditions: _______________________________________________________________
How did the accident happen? _______________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Who was at fault for the accident and why? ____________________________________________
________________________________________________________________________________
________________________________________________________________________________
Witnesses' Names, Address & Phone Numbers:
1) ______________________________________________________________________________
2) ______________________________________________________________________________
3) ______________________________________________________________________________
4) ______________________________________________________________________________
Were you questioned by the police? Yes No
Did you give or sign a statement to the police? Yes No
Have you given a statement to anyone else, e.g. insurance adjuster? Yes No
When? __________________________ Do you have a copy of the statement? Yes No
How did you leave the scene of the accident? (car, ambulance, etc)
_________________________________________________________________________________
Name of insurance company of at fault driver: ___________________________________________
DESCRIBE YOUR INJURIES/DAMAGES:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Were you physically disabled for any period of time as a result of the accident?
Dates of disability: _____________________________
Length confined to bed:_____________________________
Length of time confined to home:_________________________
MEDICAL TREATMENT INFORMATION FOR THIS ACCIDENT: Attach Extra Pages if Needed
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Doctors, hospitals, clinics, etc., providing treatment for injuries:
1) Name & Address of Medical Provider: ___________________________________________
_______________________________________________________________________________
Approximate Dates of Treatment: ___________________________________________________
Nature of Treatment: _____________________________________________________________
2) Name & Address of Medical Provider: __________________________________________
______________________________________________________________________________
Approximate Dates of Treatment: __________________________________________________
Nature of Treatment: ____________________________________________________________
3) Name & Address of Medical Provider: _________________________________________
______________________________________________________________________________
Approximate Dates of Treatment: __________________________________________________
Nature of Treatment: _____________________________________________________________
4) Name & Address of Medical Provider: __________________________________________
______________________________________________________________________________
Approximate Dates of Treatment: __________________________________________________
Nature of Treatment: _____________________________________________________________
PAYMENT OF MEDICAL BILLS FROM THE ACCIDENT
Who is Paying Your Bills? _________________________________________________
Auto/ Auto Med-Pay Worker's Comp Your Medical Insurer Self Other
Name of Auto Insurance Company at time of accident: ___________________________________
Med Pay Claim Number: Phone Number: _______________________________________
Name of Health Insurance Company at time of accident: ________________________________
Group/Contract No. Benefit phone number: ___________________________________________
List each medical provider you are aware of which has not been paid for your treatment:
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
CURRENT EMPLOYER:_________________________________________________________
Name & Address: ______________________________________________________________
Supervisor: ____________________________________________________________________
Title and Duties: _______________________________________________________________
Dates Employed: Salary/Wage: __________________________________________________
EMPLOYERS FOR LAST TEN YEARS: Attach Extra Pages if Needed
Name & Address: ______________________________________________________________
Supervisor: ____________________________________________________________________
Title and Duties: ________________________________________________________________
Dates Employed: Salary/Wage: ___________________________________________________
Name & Address: ______________________________________________________________
Supervisor: ____________________________________________________________________
Title and Duties: ________________________________________________________________
Dates Employed: Salary/Wage: ___________________________________________________
Name & Address: _______________________________________________________________
Supervisor: _____________________________________________________________________
Title and Duties: _________________________________________________________________
Dates Employed: Salary/Wage: ____________________________________________________
Have you ever been in the military? If so, state branch and dates of service: ________________
OTHER CLAIMS AND LAWSUITS - Failure to disclose prior injury claims and lawsuits will severely diminish your case. Please list every claim that you have ever made for personal injury or property damage and give details. This includes workers compensation claims. Add additional pages if necessary.
Include the Date and place of incident, Nature of claim, Extent of injury, Claim made against whom. whether a lawsuit was filed? If so, where and when? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
OTHER ACCIDENTS OR INJURIES
You may have been involved in another accident or injury that didn't result in a claim being made against someone. Please list all of those here. Add additional pages if necessary.
Date and place of incident: _________________________________________________________
Nature of accident or injury: ________________________________________________________
Extent of injury: __________________________________________________________________
List all medical providers who treated you for any of the above injuries, accidents or claims:
Name and Address: ______________________________________________________________
Name and address: ______________________________________________________________
Name and address: ______________________________________________________________
ACCIDENTS OR INJURIES AFTER THIS ONE
Date and place of incident: _________________________________________________________
Nature of accident or injury: ________________________________________________________
Extent of injury: __________________________________________________________________
List all medical providers who treated you for accidents or injuries after this one:
Name and address: _______________________________________________________________
Insurance company(ies) involved in any accidents or injuries after this one: __________________
________________________________________________________________________________
MEDICAL CARE BEFORE AND AFTER THIS INJURY
List the names and addresses (or at least the cities) of all primary care physicians you have had for the last 10 years. If you have had a doctor who has followed you for a medical condition in addition to your primary doctor, please list that provider as well (attach extra pages as necessary):
Name and Address: _________________________________________________________________
Name and address: __________________________________________________________________
I have read and completed this data sheet and I swear that it is true and correct. I understand that providing false or misleading information may result in the attorney's withdrawal from representation of me on this case.
Date:___________________________________
Signature:_______________________________
Please return to:
Murray & Damschen, P.C .
1536 Cole Blvd., Suite 335
Lakewood, CO 80401
Phone: (303) 274-7752
Facsimile: (303) 274-7942