Personal Injury

Personal Injury Questionnaire

Thank you for choosing Tracey Fox & 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

    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

    Claim Number
    Adjuster's Name & Number

    Client's Insurance Information

    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