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Personal Injury Client Questionnaire

Personal Injury Client Questionnaire

Please share details regarding your person and your injury below so we can better understand your case.

Personal Information

Please provide background information to help us understand how to contact you and who your family members are.

Name *

First

Middle

Last

Email *

Social Security Number *

Marital Status *

Spouse's Name *

First

Last

Do you have any children? *

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Please list each child's name and birth date. *

Are you active on any social media platforms? *

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Employment Information

Employer *

Enter "none" if you are unemployed.

Position Title *

Job Description & Duties *

Employer's Address *

Address Line 1

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City

State

Zip Code

Hourly Wage or Annual Salary *

Overtime Wage (if applicable)

Insurance Information

This information helps us understand the important entities responsible for helping you recover financially from your injury / incident.

Client Health Insurance Carrier *

Enter "none" if you do not have health insurance.

Health Insurance Card

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Please upload an electronic copy of your health insurance card, if you have one.

Do you have a Medicare card? *

Client Auto Insurance Carrier

Do you have Short Term Disability insurance? *

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Not sure

Short Term Disability Insurance Carrier *

Do you have Worker's Compensation insurance? *

Yes
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Worker's Compensation Insurance Carrier *

Adverse Party's Insurer

Injury Information

Date & Time of Injury *

Date

Time

Address Where Incident Occurred *

Address Line 1

Address Line 2

City

State

Zip Code

Description of injury/injuries *

Did anyone witness the incident? *

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No

Please list names and contact info for each witness. If you do not have this information, please describe any witnesses as best you can. *

Please upload any photos or videos you have related to the incident

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Was a police report generated as a result of the series of events leading to your injuries? *

Police Report

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Please upload an electronic copy of your police report, if you have one.

Post-Incident Information

Help us understand the important events after your incident and what the consequences of any injuries.

What hospital were you transported to due to your injury?

Were you transported to a hospital in an ambulance due to your injury? *

Have you had any of the following tests for your injuries? *

Labs
MRI
CT Scan
X-ray Imaging

Have you given written or verbal statements to regarding the incident to any of the following: *

Insurance company
Police
Employer
Other
None

Is your injury related to a workers compensation claim? *

Worker's Compensation Attorney

Have you or will you miss time for work as a result of your injury?

How much time did you miss (or will you miss) from work?

Have you ever injured or treated this area prior to this accident? *

Have you received any billing or collection notices? *

Yes
No

Please upload digital copies of any billing or collection notices you have received.

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Are you receiving any benefits or other forms of income such as unemployment insurance or social security disability insurance? *

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Not sure

Please list and describe any benefits you currently receive:

Other comments or details you find important or relevant?

Milwaukee

5150 N. Port Washington Rd, Ste 243
Milwaukee, WI 53217-5470
Phone: 414-271-8650
Fax: (414) 207-6079

Mon - Fri | 8:30 to 5:00
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Appleton

54 Park Pl, #400
Appleton, WI 54914
Phone: 920-931-2560
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Madison

409 E Main St
Madison, WI 53703
Phone: 608-257-0040
Fax: (608) 256-0236

Mon - Thu | 8:30 to 5:00
Fri | 8:30 to 2:00
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Kenosha

3103 52nd St
Kenosha, WI 53144
Phone: (262) 228-4990
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Chicago

111 E. Wacker Drive, Ste 2300
Chicago, IL 60601
Phone: (312) 262-7517
Fax: (414) 207-6079

Mon - Thu | 8:30 to 5:00
Fri | 8:30 to 2:00
Map | Attorneys

Waukesha

500 Elm Grove Rd, Ste 205
Elm Grove, Wisconsin 53122
Phone: 262-439-4450
Map | Attorneys

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© 2024 Hawks Quindel, S.C. All Rights Reserved. Site by Isthmus Design. Custom Photography by Nick Wilkes Photography.

Hawks Quindel represents clients throughout the State of Wisconsin, including the cities of Milwaukee, Madison, Green Bay, Kenosha, Racine, Appleton, Waukesha, Eau Claire, Oshkosh, Janesville, West Allis, La Crosse, Wauwatosa, Sheboygan, Fond du Lac, New Berlin, Wausau, Menomonee Falls, Brookfield, Oak Creek, and Beloit among others statewide.

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Choose an Office

Milwaukee

(414) 271-8650
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Madison

(608) 257-0040
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Appleton

(920) 931-2560
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Eau Claire

(715) 830-1378
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Kenosha

(262) 228-4990
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