Phone * Email * Social Security Number Driver's License Number * VIN Number of your vehicle * Marital Status * Single, Never Married Married Separated Divorced Widowed Spouse's Phone Project Overview Health Insurance Information Do you have health insurance coverage? * Company Name: * Policy Number: * Are you on the following? * Medicare Medicaid Peachcare None of the above Employment History Occupation / Job Title: * Job Description: * Professional Licenses / Certifications: * Current Employer Information Name of Employer: * Business Phone * Immediate Supervisor's Name: * Supervisor's Email: * Supervisor's Phone: * Annual Salary (if applicable) * Hourly Rate (if applicable) * Other Compensation (if applicable) * Typical Weekly Schedule *
(e.g.: Mon 9-5)
Total Amount of Work Missed as a Result of This Incident (to date): Your Automobile Insurance coverage
If you don't know the answer to a question, write "unknown". Please obtain a copy of your insurance policy declaration page along with any riders and bring them with you to your consultation.
Name of Insurance Carrier: * Policy Number: * Agent Phone * Agent Email * Do you have information about the at-fault party's insurance? * Incident Facts Were you the Driver or the Passenger in the vehicle? Please provide a Detailed Description of the Incident: * If no, why not? Citation / Traffic Ticket Issued? If yes, to whom? If yes, Citation Number: Hearing Date and Location: Police Report / Case Number: How did you leave the scene of the incident? Did anyone leave the scene of the incident in an ambulance? If yes, whom? Please describe their injuries, if known: Vehicle Occupants List All Vehicle Occupants, Their Addresses, and Their Phone Numbers (List Driver First if Not You): List All Other Witnesses, Their Addresses, and Their Phone Numbers (List Driver First if Not You): (copy) Property Damage Describe damage to your vehicle: Describe damage to other vehicles involved: Do you have photographs of your vehicle? Name of Mechanic: Mechanic's Phone Bodily Injuries Describe the nature of your bodily injuries: On a Scale of 1-10, please state the level of your pain: Do you have photographs of your injuries? Any Serious Pre-Existing Medical Problems? Did Your Injury Aggravate Any Pre-Existing Medical Problems? If yes, please explain: How have your injuries changed your lifestyle?
BE SPECIFIC - THIS INFORMATION IS VITAL!!
Generally: Sexual Activities: Social/Recreational Activities: Job-Related Activities: Household-Related Activities: Doctors and/or Facilities
Please Provide Information Regarding Doctors and/or Facilities That Have Treated You Since This Incident.
Doctor's Name Doctor's Phone Other Helpful Information Have You Ever Been in Any Other Accidents in Which You Suffered Injuries That Led To Any Medical Care, Consultation, Exams or Treatment? If Yes, Please Explain the Circumstances: Have you ever made a claim against any person or organization for damages to your person or property? If Yes, Please Explain the Circumstances: Have you ever received a citation for DUI? If Yes, Please Explain the Circumstances: Upload photos of vehicle damage here:
How did you hear about C. Kelly Law, LLC? Disclaimer: Submission of this form does not create any type of attorney-client relationship. * I agree
By agreeing to this disclaimer, you represent that the information provided by you in this document is accurate and true to the best of your knowledge.