PI Intake Form - Premises Liability - Foster Graham Milstein & Calisher

Premise Liability intake form

Fill out this form if injured from premises liability. Otherwise, choose from one of the following:

Motor Vehicle Crash Medical Malpractice

Our unified team of dedicated and experienced attorneys can help.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Who may we thank for referring you to our office?

Who was injured in this accident?

Date of birth of injured person

Last 4 digits of SSN

Date of injury

Location of injury

Include address and name of establishment if relevant

Describe what happened that caused injury

List the name, address and phone numbers of the person(s), owner(s), company, business or establishment that you believe caused the injuries

Does the establishment have footage of the incident?

Did you report the incidient right away? If not, when?

List their insurance company, phone number, address and claim number, if you know it

List the names, phone numbers and addresses of any witnesses to the accident.

If you do not know all of this information provide what you know.

What are your injuries and what is your current condition

List your health insurance company information AND, if applicable, disability policy information (company, policy number, address and phone) IF you are utilizing your health insurance to care for your injuries

Is this health insurance privately purchased OR is it provided in whole or in part through your employer or your spouse’s employer?

How much time have you missed from your job, and are you utilizing any temporary disability insurance during your recovery?

How much income have you lost? How much do you expect to lose? And how is this lost income determined?

Please list all out of pocket losses you have incurred as a result of this injury.

List your doctors/physical therapists etc. that you have treated with as it relates to this case.

Please include your doctors’ names, addresses and phone numbers, as well as why you are seeing this doctor.

Please provide any other information you believe will assist our office in resolving this matter.

Name of Ambulance company that transported you.

This field is for validation purposes and should be left unchanged.