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