Name: Quirk Law Group
Address: 1295 West Sunset Blvd, Los Angeles, California, 92101
Telephone: 619-356-2901

Interview Slip and Fall

INVESTIGATION INFORMATION

Interview Slip and Fall

Client Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
SSN#*
Emergency Contact*
First Last
Phone*
Marital Status*
- Married
- Single
Spouse's Name (If applicable)
HEALTH INSURANCE
Does Client have Health Insurance?*
Does client have Government Insurance? (eg. Medicare)*
Health Insurance Carrier
Phone #
Subscribers Name
First Last
Member #
PSYCHOLOGICAL DAMAGE
Please Describe
MEDICAL PROVIDERS
Was Client treated by Paramedics?*
Was Client transported to Hospital via Ambulance?*
Name of First Hospital/ Doctor Seen*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
X-Rays Taken?*
Name of Other Doctor's Seen
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Other's Seen
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Has Client received any medical bills?*
If yes, please submit
EVIDENCE
Police Report/Agency
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Report #
Received by Investigator*
Bodily Injury Photos*
EMPLOYMENT INFO
Employer Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Position Title*
Time Missed from Work*
Pay Rate*
Who is the contact person to verify time missed from work?
First Last
Phone
DETAILS OF ACCIDENT
Date*
Date Format: MM slash DD slash YYYY
Time*

: HH

MM
Location (street/city)*
Describe what happened*
What/where are your injuries/pain complaints?*
Did you lose consciousness?*
Were there any witnesses?*
Have you had any previous accidents/injuries?*
Anything else you would like to mention?*
CAPTCHA

03/22/2019
By Brian Hansen

Interview Slip and Fall

Interview Slip and Fall

INVESTIGATION INFORMATION

Interview Slip and Fall

HEALTH INSURANCE

PSYCHOLOGICAL DAMAGE

MEDICAL PROVIDERS

EVIDENCE

EMPLOYMENT INFO

DETAILS OF ACCIDENT