Client Personal Injury Application
Auto Accidents Only
*Indicates a required field
Client Information:
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First Name:
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Last Name:
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Social Security #:
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Address:
Apartment/Suite:
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City:
*State:
*Zipcode:
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Home Phone:
Work Phone:
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Date of Birth:
E-Mail Address:
Occupation:
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Employer:
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Amount Requested:
$500
$750
$1000
$1500
$2000
Other
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I have a Personal Injury Law Suit/Claim/Action:
Accident Description:
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Date of Accident (mm/dd/yyyy):
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Type of Vehicle:
Cargo Van
Motor Cycle
Passenger Car
Passenger Van
SUV
Truck - Pickup
Truck - Other
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Position in Vehicle:
Driver
Motorcycle Driver
Motorcycle Passenger
Passenger Back
Passenger Front Seat
Pedestrian/Bicyclist
Other
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Type of Accident:
Collision - One Vehicle
Collision - Two Vehicles
Collision - More Than Two
Loss of Control
Pedestrian Struck
Rollover
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Impact:
Driver Side
Front (Head On)
Passenger Side
Rear
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My Vehicle was:
Moving
Stopped
Injuries/Damages:
Vehicle Damage:
Less than $2000
Greater Than $2000
Don't Know
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Emergency Room:
I did not go to the emergency room.
I went to the emergency room in an ambulance.
I went to the emergency room immediately under my own power.
I went to the emergency room later that day.
I went to the emergency room the next day.
I went to the emergency room two or more days later.
I was admitted to the hospital:
Stayed Overnight
# of Days in Hospital
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Most Serious Injury:
Fatality
Minor Lacerations/Contusions
Serious Laceration
Scarring
Neck Sprain or Strain
Back Sprain or Strain
Other Sprain or Strain
Knee
Disc Injury
Fracture of weight -bearing bone
Other Fracture
Internal Organ Injury
Concussion
Permanent Brain Injury
Loss of Body Part
Paralysis/Paresis
TMJ Dysfunction
Loss of Senses
Psychologoical/Emotional
Unknown
Other Injury
Describe Your Injury:
(for those questions that have multiple responses, please hold down the control key to choose more than one answer)
Health Care Providers that treated me:
General Practioner/Internist
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Procedures - Other:
X Ray
MRI
CT
EMG
Muscle Strength Evaluation
H Reflex Study
Thermography
Bone Scan
Somatosensory
Lab Studies/Blood Work
Neuro-psychological Evaluation
Anthroscopy
Other Diagnostics
Comments:
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I am still being treated:
Yes
No If no, when were you released? (mm/dd/yyyy)
Lost Wages
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I have a lost wages claim:
Yes
No
Disability
If you have a disability as a result of this accident, please explain:
Liability/Insurance
The Police Arrived At The Scene
The defendant received a ticket
Defendant was injured
Defendant's insurance company paid for the property damage to my car.
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Defendant's Insurance Company:
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My Insurance Company:
I have un-insurance motorist coverage. Amount:
I have under-insured motorist coverage. Amount:
I have a loss of consortion claim.
Attorney Information
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Name:
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Firm:
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Address:
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City:
State:
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Zip:
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Telephone:
Fax:
Paralegal:
12140 Lackland Road
St. Louis, Missouri 63146
Phone 314.446.3600
Fax 314.446.3601
St. Louis, Missouri 63146 Phone 314.446.3600 Fax 314.446.3601