Personal Injury Fact Sheet
Today's date: _________________________________ 1.
Plaintiff name: _________________________________
address: _________________________________
phone home: _________________________________
d/o/b: _________________________________
Soc.. security: _________________________________
Spouse _________________________________
2a. Date of Accident: _________________________________
town, county, state: _________________________________
day of week _________________________________
time: _________________________________
weather _________________________________
Road conditions _________________________________
2b. Operator of Plaintiff's car: _________________________________
Owner of Plaintiff's car: _________________________________ _________________________________
2c Other occupant's of Plaintiff's car. _________________________________
2d Street Plaintiff was traveling on: _______________________
Direction of travel (ex- North, south, etc.): _________________________________ _________________________________
Nearest approaching road: _________________________________
2e Street Defendant was traveling on: _________________________
Defendant Direction of travel (ex- North, south, etc.): _________________________________ _________________________________
Nearest approaching road: _________________________________
2f Traffic lights or stop signs in area: __________________________
2g Description of Accident: _________________________________
3. INJURIES- NATURE, EXTENT, DURATION
4. PERMANENT INJURIES AND PRESENT COMPLAINTS
5. HOSPITALS- ADDRESS, DATE OF ADMISSION DISCHARGE
6- X-RAYS, TAKEN BY: _________________________________
ADDRESS _________________________________
DIAGNOSTIC TESTS: _________________________________ _________________________________
X-ray, MRI DATE _________________________________
RESULTS _________________________________
7 DOCTOR-NAME _________________________________
ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
7B. MEDICAL PROVIDER-NAME __________________________
ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
7C MEDICAL PROVIDER-NAME ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
8. STILL BEING TREATED? MEDICAL PROVIDER-NAME NATURE OF TREATMENT AND NATURE OF TREATMENT
9. AGGRAVATION OF PRIOR INJURIES BY ACCIDENT, PRIOR DOCTOR
10. Employer Name: _________________________________ Address: _________________________________ Job/Position Gross/week Net/week Time Lost Total Wages Lost: _________________________________
11. IF RETURN TO WORK: _________________________________ Current Employer Name: _________________________________ Address: _________________________________ Job: _________________________________ ________________________ Gross/week Net/week
12- OTHER LOSS OF INCOME, EARNINGS
13. Medical bills, Doctor Amount unpaid Paid hospital bills, medicine, etc. Total medicals (As of ________): _________________________________
14. OTHER OUT OF POCKET EXPENSES and OTHER LOSSES
15. Relevant Documents: _________________________________ _________________________________ Identify all documents that may relate to this action, and attach copies of each such document, such as police report, hospital bills, etc. Police Report: _________________________________ _____________________________________________ Declaration Sheet: _________________________________ _________________________________ ____________ Hospital Bills: _________________________________ _________________________________ ____________ Hospital Records: _________________________________ _________________________________ ____________ Medical Bills and Records ____________ Photographs of Accident Site: _________________________________ _________________________________ ____________ Photographs of Damage to Plaintiff's car: _________________________________ _________________________________ ____________ Photographs of Damage to Defendant's car: _________________________________ _________________________________ ____________ Photographs of Injuries, scars, cuts: _________________________________ _________________________________ ____________ Repair damage estimate: _________________________________ _________________________________ ____________
Other: _________________________________ _________________________________ __________
16a defendant name: _________________________________ _________________________________ address: _________________________________ _________________________________ Owner of Def car: _________________________________ address: _________________________________ Type of car: _________________________________ ___________________________ make, year Other occupants of def car
16b Eye witness name: _________________________________ address & phone: _________________________________
17 Names and addresses of People with Relevant Knowledge
Officers of Investigating Police Department: _________________________________
18. Photographs: _________________________________ _________________________________ If any photographs, videotapes, audio tapes or other forms of electronic recordings, sketches, reproductions, charts or maps were made with respect to anything that is relevant to the subject matter of the complaint, describe: _________________________________ _________________________________ (a) the number of each; (b) what each shows or contains; (c) the date taken or made; (d) the names and addresses of the persons who made them; (e) in whose possession they are at present; and (f) if in your possession, attach a copy, or if not subject to convenient copying, state the location where inspection and copying may take place. ___________
19. If you claim that the defendant made any admissions as to the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date made; (b) the name of the person by whom made; (c) the name and address of the person to whom made; (d) where made; (e) the name and address of each person present at the time the admission was made; (f) the contents of the admission; and (g) if in writing, attach a copy.
20. If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication.
21. If you have obtained a statement from any person not a party to this action, state: _________________________________ _________________________________ (a) the name and present address of the person who gave the statement; (b) whether the statement was oral or in writing and if in writing, attach a copy; (c) the date statement was obtained; (d) if such statement was oral, whether a recording was made, and if so, the nature of the recording and the name and present address of the person who has custody of it; (e) if the statement was written, whether it was signed by the person making it; (f) the name and address of the person who obtained the statement; and (g) if the statement was oral, a detailed summary of its contents. _____________________________
22: _________________________________ ___________________________ Violation by Defendant of Motor Vehicle law (i.e. Careless driving or other statute
23. Expert witnesses: _________________________________ 24. Have you every been indicted and convicted of a crime? ______ (This question required by Rules of Court)
25a Plaintiff car ins company: _________________________________ THRESHOLD address: _________________________________ phone: _________________________________ policy # claim # year, make, model collision coverage Who Notified? UM/ UIM coverage
25b Named Insured: _________________________________ _________________________________ _____________________________________
25c Copy of Dec Sheet: _________________________________
25d. Plaintiff's private major- medical ex- Blue Cross address: _________________________________ phone: _________________________________ Policy number
26a: Distance between Plaintiff and point of impact when first observed other vehicle and Plaintiff's speed: _________________________________
26b: distance between Plaintiff and the Defendant's vehicle when first observed other vehicle: _________________________________ ___________________________________________________________
26c: Where Plaintiff's vehicle came to rest and where Defendant's vehicle came to rest: _____________________________ ___________________________________________________________
27: Part of Plaintiff's car hit by Defendant's car: _________________________________ ________________________________________________________
Damage to Plaintiff's car: _________________________________ _________________________________ _______________________________________
Property damage estimate: _________________ ___________________________________________________________
28: Where Plaintiff was coming from and where Plaintiff was going to: _________________________________ ___________________________________________________________
29. Parts of body hitting car: _________________________________ _________________________________ _____________________
30. Unconsciousness? _____________________
31. Skid marks by any car: _________________________________ _________________________________ _____________________
32. Defendant's Ins carrier 33. address: _________________________________ phone: _________________________________ 34. adjuster: _________________________________ 35. Policy limits: _________________________________ claim #: _________________________________
36. When did you apply your brakes?: ___________________________ _________________________________ _____________________
37. How fast were you going?: _________________________________ _________________________________ _____________________
38. How fast was the Defendant going?: _________________________________ _________________________________ _____________________
39. Describe the position of each car at the point of impact, giving distance from curb, lines, streets or other landmarks?: _________________________________ _________________________________ _____________________
40. Alcoholic beverages or medication within 12 hours before accident? _______
41. Prior accidents involving injury in which you received an insurance settlement or suit was started? (Including worker's compensation)? Prior car accidents with only property damage? _____________________
42. Negligent actions by Defendant: _________________________________ _________________________________
43. What else did you tell police? _____________________
44. Set forth the names of insurance agents and other individuals you discussed the case with an what did you say? _____________________
45. Please prepare a Diagram of the accident site _____________________
46. Are you receiving Medicare/ Medicaid? ___________ Are you receiving SSI? ___________
Is there anything else important? ___________________________
___________________________________________________________ ___________________________________________________________
Documents to be supplied to attorney & in his possession: Police Report: _________________________________ Declaration Sheet: _________________________________ Medical/ Hospital Bills and Records: _________________________________ Photographs of Accident Site: _________________________________ Photographs of Damage to Plaintiff's car: ___________________________ Photographs of Damage to Defendant's car: _________________________________ Photographs of Injuries, scars, cuts: _________________________________ Repair damage estimate: _________________________________
