Client Questionnaire for Personal Injury Clients

Please complete this form so we can get up to speed on your file as quickly as possible.

Name *
Phone *
Email *
Health Insurance * Medicare Medicaid HMO PPO No Health Insurance
Health Insurance Name (e.g. "Blue Cross Blue Shield")
Health Insurance Policy #
Health Insurance Group #
Car Insurance Name
Car Insurance Policy #
Car Insurance Claim #
Name of Employer
Job Title
Have you missed work due to your injuries? Yes No
If yes, what is your weekly income?
Describe in detail how you were injured. *
List the names of any witnesses.
List all body parts that were injured with a description of symptoms for each body part.. *
List the names and health groups of all doctors who have provided medical treatment for your injuries along with a brief description of the treatment each provided.
Have you filed for bankruptcy in the last 7 years? Yes No
Have you been convicted of a felony? If so, list them here along with approximate date of conviction and if time was served, the date you were released.
Have you been convicted of a misdemeanor involving theft of dishonesty? If so, list them here along with approximate date of conviction and if time was served, the date you were released.
List a brief description and estimated date for any prior personal injury claims you have made.
List a brief description and estimated date for any prior workers' compensation claims you have made.

***After clicking submit, you will be provided a link to upload all pictures, videos, documents, records, etc. to our system.

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To fill out your own intake and get a call back from one of our attorneys ASAP, click HERE and select your case type.

Otherwise, to get a call back from our intake specialist, please fill out this form to schedule your own free case consultation. Please be sure to include your name, contact information, and any necessary details about your case. Our intake specialist will call you as soon as possible.

*By pressing the Submit button and providing my cell phone number, I agree to receive phone calls and/or text messages from Marker & Crannell regarding this inquiry. Message & data rates may apply. Reply “STOP” at any time to cancel.