[VLN-Trucking] TRGP - Morelli Law Intake Questionnaire

First Name *

Last Name *

2. Your present address *

Tel *

3. Cell

Email *

4. Provide your social security number

5. Provide your date of birth *

6. Date/Time of the accident *

7. Your address on D/A *

8. Exact location of the accident (please be as specific as possible) *

9. Description of the accident (please be as specific as possible) *

10. What is the name of the trucking company involved in the accident? (if you know) *

11. Injuries (including surgeries if any) *

12. Names and addresses of all hospitals and doctors that treated you because of this accident *

13. Do you receive welfare, public assistance, medicaid or medicare? If so, please provide the names and addresses: (IF NONE B WRITE NONE!) *

14. Name and address of your employer on the date of the accident. Weekly wages and/or yearly salary earned and employment dates: (IF NONE B WRITE NONE!) *

15. Number of days lost from work due to the accident: (IF NONE B WRITE NONE!) *

16. Number of days confined to hospital due to the accident: (IF NONE B WRITE NONE!) *

17. Names and addresses of witnesses to the accident: (IF NONE B WRITE NONE!) *

18. Please provide all medical bills related to this accident

19a. Do you owe any money out of pocket to doctors, hospitals or medical facilities due to the accident? *

19b. How much?

19c. How much have you already paid to doctors due to the accident?

20. Do you have any photos or videos of the accident and/or accident site? (If yes, you will need to email them to the law firm.) *

21. Do you have a copy of the ambulance or Police report from the day of the accident? (If yes, you will need to email them to the law firm.) *

22a. Before this accident (that is the subject of this litigation), did you receive any past medical care for any part of your body that was now injured in this accident (that is the subject of this litigation)? *

22b. If so, which parts of your body were treated before the subject accident?

23. Please list the names and addresses of all doctors and hospitals that treated you before this accident (that is the subject of this litigation) for the injuries in no. 22

24a. Before the accident (that is the subject of this litigation), did you have any other accidents in which you injured any of the parts of your body that were injured in the accident that is the subject of the present litigation? *

24b. If so, which parts of your body were injured before?

25. Please list the names and addresses of any attorney who represented you in a personal injury case before seeking representation at our firm: (IF NONE PLEASE WRITE NONE) *

26. What was the date(s), location(s) and description of the prior accident(s) of the other accident(s)?

27a. Have you ever been convicted of a crime? *

27b. If so, when?

27c. What crime?

28a. Have you ever declared bankruptcy? *

28b. If so, when?

29a. Are you or have you ever been married? *

29b. Please list their name(s) and addresses below

30a. Do you have any children? *

30b. If so, please list their name(s), age(s) and addresses below

31. If you have never been married or have no children, please list any close family members below

Any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain money, or who knowingly accepts money to which that person is not entitled, is subject to civil remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both. MORELLI LAW FIRM PLLC, does not, and never will, represent a fraud.

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