C
olorado
L
aw.com
Client Information Sheet
Slip and Fall
Personal Information
Full Name:
Birthday:
Address:
Social Security Number:
City:
State:
Zip Code:
Phone, Work:
Home Phone:
Spouse: Name:
Work Phone:
Name of person other than your spouse who should always know your whereabouts:
Name:
Relationship:
Work Phone:
Home Phone:
Accident Information
Accident Date:
Time of Day:
Location: (please be specific)
Property owner
Name:
Address:
Property Management Company
Name:
Address:
Weather Conditions:
How did the accident happen?
Who did you report the incident to:
Name:
Address:
Was a written report completed?
Y or N
Yes
No
Do you have a copy of the report?
Y or N
Yes
No
Were photographs taken of the location where you fell?
Y or N
Yes
No
Were there any witnesses to the incident? if so...
Name:
Address:
Name:
Address:
Medical Information
Were you injured in this incident? Describe:
Were you treated at a hospital immediately following the incident?
Y or N
Yes
No
Were you taken by ambulance to the hospital?
Y or N
Yes
No
Name of ambulance service:
Name of hospital:
Address:
Were X-rays taken?
Y or N
Yes
No
Are you under the care of a Physician now?
Y or N
Yes
No
List all doctors that have treated you for this incident:
Name:
Address:
Telephone:
Date of last appointment:
Name:
Address:
Telephone:
Date of last appointment:
Name:
Address:
Telephone:
Date of last appointment:
What is the approximate amount of your medical bills?
Have you had any other injuries, either before or after this accident?
Y or N
Yes
No
Describe:
Loss of Wages
Were you employed at the time of this incident?
Y or N
Yes
No
Name of employer:
Address:
Occupation:
How long have you worked there?
Hours worked per week:
Regular hourly wage:
Overtime per week:
Overtime Rate:
Are you working now?
Y or N
Yes
No
If time lost from work:
Regular hours lost from work:
Overtime hours lost from work:
Total loss of wages to date:
If you are not employed, please identify:
Last employer:
Address:
Last date you worked there:
Insurance Information
Property owner's insurance company:
Policyholder:
Policy/Claim number:
Adjustername:
Address:
Do you have other insurance (though employer, Medicaid, etc.) to which medical bills have been submitted? If so:
Name:
Address:
Policy Number:
Has anyone from the property owner's insurance company contacted you?
Y or N
Yes
No
When?
To whom did you speak?
Did you give a written or recorded statement?
Y or N
Yes
No
Do you have a copy?
Y or N
Yes
No
How did you hear about Colorado Law.com:
Select one
Yellow Pages
Friend/relative
TV
Other
If TV, what time of day did you see the advertisement:
select a time
morning
afternoon
night
late night
[an error occurred while processing this directive]