Employment Case Intake Form

We would like you to complete this Initial Consultation Form in order to assist us in evaluating your case. Reviewing your Consultation Form does not mean that Wagner, Jones, Kopfman & Artenian LLP has agreed to act as your attorneys. We are agreeing only to evaluate the facts presented in your Consultation Form responses to determine whether we can assist you.

Your Email (required)

Referred BY:

MR/Ms.
Mr.Ms.

Name

DOB:

DOI:

Phone Number:

Message Phone:

How did the accident occur?

Describe your injuries resulting from this accident:

Have you sought medical attention?
YesNo

Still Treating?
YesNo

When?

Total medical bills incurred to date?

Doctor(s) Name, address, & phone number:

Medical diagnosis?

Police Report?
YesNo

Accident report?
YesNo

Please list your lost wages to date:

Your employer:

Rate of pay:

Date of Hire?

Do you have a claim for unpaid meal time, over time, vacation time, sick time or breaks?
YesNo

Have you, or do you plan to file bankruptcy?
YesNo

FOR AUTO ACCIDENTS:

Estimate amount in dollars to repair?

Part of auto damaged?

Location of Accident?

Other person(s) have insurance ?
YesNo

Do you have insurance?
YesNo

Your insurance agent's name:

Address:

Phone Number:

Defendant's insurance information:

Claim Number:

Adjuster

Pictures?
YesNo

What of?