Personal Injury Case Evaluation Form

FISHKILL OFFICE:

1436 Route 52
Fishkill, NY 12524
(845) 896-4711

HOPEWELL JUNCTION OFFICE:

740 Route 82
Hopewell Junction, NY 12533
(845) 226-4559

Personal Injury Case Evaluation Form

Attorney Robert P. Ianelli

1436 Route 52 Fishkill, NY 12524
Tel: 896-4711 Fax: 896-4755
www.ianelli.com
E-Mail: rianelli@ianelli.com

New Client Intake Information

Instructions: Please provide the information requested below. If you are unsure of any answer, consult with us for clarification or assistance.

1. *Name:
2. Address:
3. Mail Address: [if different from 2]
4. Tel. Home:
Tel. Work:
Tel. Other:
Cell No:
5. *E-mail:
6. Birth Date:
7. Accident Date:
8. Marital Status [check one]	M S Div.
9. Name of Spouse:
10. Dependent Children:
11. Name DOB:
12. Employer:
Name:
Address:
Telephone:
Job Title:
13. Accident Type:
Automobile	1 Veh 2 Veh 3 Veh More
Premises	WorkOther
Construction/Labor Law Med Malpractice Dog Bite Other
14. Accident Report:	Y N
15. Medical Care:
Ambulance	Alamo SW Other
ER Room	SFHVBHOther
Other Physician
Diagnostic:	YNMRICat
16. Prior Medical:	YN
17. Prior Lawsuits:	YN
Date:
Venue:
18. Witnesses:
Name
Address
19. Photographs:
Scene
Damage to Autos	RepairTotal Loss
Injuries Other
20. Client Insurance Carrier:
Own Auto
Carrier Name:
Other party auto Health Carrier WC Carrier Disability Carrier
21. Referred From:
Prior Client Name:
Other:

Note: It is important that you provide accurate information. If you are not sure, please ask.

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Note: The information contained herein is for informational purposes only and is not to be considered legal advice. Only your lawyer can give you legal advice. If you have a legal question, you should consult with an experienced injury attorney as soon as possible.