Personal Injury
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Home ยป Personal Injury Questionnaire

Personal Injury Questionnaire

Thank you for choosing Tracey Fox King & Walters to handle your case. Please fill out the questionnaire on this page so that we can move your claim forward expediently.

Plaintiff Information

Were you injured?
Type of injury
Type of accident/event
Date of accident/event
Location of accident/event
Was an accident or crash report made?
Name of the reporting agency (HPD, HCSO, etc.)
Do you have a copy of the accident report? If yes, please send a copy of the report via fax or email.
Defendant #1 Name
Defendant #2 Name
Defendant #3 Name
Have you ever been represented by an attorney before?
Previous similar accident(s)?
If yes did you:

Medical Treatment Information

Provider
Date(s) of Service
Type of Treatment (transport, ER, surgery, PCP/follow up, PT)
Are you still treating?
Do you have any out of pocket expenses for treatment?
If yes, please send a copy of any receipts, statements, etc.
Previous injuries or medical conditions?
If yes, please list them out:

Auto or Homeowners' Insurance Information

Have you spoken with any insurance companies or adjusters?
If yes, please give specifics:
To whom and with which company - yours or other driver's?
Did you give a recorded statement?

Liability Carrier's Information

Company
Claim Number
Adjuster's Name & Number

Client's Insurance Information

Company
Claim Number
Adjuster's Name & Number
Coverage Available:

Employment Information

Employer at the time of the accident/event
Dates of Employment
Lost time or wages as a result of the accident/event?
If yes:
Salary or Hourly Wage
Hours Missed Due to Accident

Additional Notes

Houston
440 Louisiana Street, Unit 1901
Houston, TX 77002
(713) 495-2333
Dallas
1412 Main Street Suite 623
Dallas, TX 75202
(214) 363-4480
San Antonio
6243 W. Interstate 10 #1011
San Antonio, TX 78201
(210) 375-4812