Todays Date* MM slash DD slash YYYY
Type of Case* Car Accident Drunk Driver Car Accident Hit and Run
What type of case is this?
First Name of Main Contact*
Your First Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
Middle Name of Main Contact
Middle Name
Last Name of Main Contact*
Last Name. This is where you enter the name of the Main client. If the injured person is a child, then you would enter their Parent's information here, not the child or deceased victim.
Suffix of the Main Contact
For example, Jr., III, Esq.
How did you find the law firm of Jebaily Law Firm, P.A.?* Thank you for sharing with us how you found Jebaily Law Firm, P.A.
Name of Friend who referred you to Jebaily Law Firm, P.A. First Last
Name of Attorney who referred you to Jebaily Law Firm, P.A.* First Last
Please tell us the name of the Attorney who referred you to Jebaily Law Firm, P.A.
My Relationship to Injured Person is that:* Your Contact Address* This is the address where we will mail any documents relating to the case.
Main Contact's Cell Phone Number:
Main Contact's Phone Number:
Main Contact's Phone Number:
Main Contact's E-mail address: Main Contact's Facebook web address is:
What is your Facebook web address? Example https://www.facebook.com/jebailylaw
Main Contact's Social Security Number is:
Main Contact's Date of Birth is:* Enter the person's birth date
Main Contact's Gender is:* Male Femaile
Main Contact's Language:* English Spanish Only Spanish Mostly Spanish Some Vietnamese Only Vietnamese Mostly Vietnamese Some
Emergency or Alternative Contact if we can't find you
Please enter the name and any other information of who we can contact if for any reason we cannot contact you.
End of contact information for Main Contact, beginning of contact for other person who is injured or deceased First Name of the Injured Person*
Your First Name. This is where you enter the name of the Injured Person or deceased victim.
Middle Name of the Injured Person
Middle Name
Last Name of the Injured Person*
Last Name. This is where you enter the name of the Injured Person, child or deceased victim.
Suffix of the Injured Person
For example, Jr., III, Esq.
End of Client Work History --- DATE OF LOSS This is the end of the Main Client Contact information, and if they are the Parent of an injured child, or the PR of a deceased person, or a Guardian of an incompetent, then we gather the injured person's basic information here.
Date of Incident/ Accident* Time of Incident / Accident Beginning of LIABILITY State where crash happened* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Select the State where the Crash happened
Location of the accident*
Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
Who owned the vehicle the injured person was in at the time of the collision? Name of the person who owned the car the injured person was in at the time of the collision First Last
The name of the company that owned the vehicle that the injured person was in is:*
Do you have the address of the owner of the vehicle the injured person was in at the time of the crash? Yes, I know the address of the owner of the vehicle the injured person was in. No, I don't have the address of the owner of the vehicle.
Address of the vehicle owner that the Injured person was riding in at the time of the collision Was the Injured Person wearing their seat belt at the time of the collision?* How many vehicles were involved in the collision?* Was the Injured Person aware that collision was going to happen before it did? What was seen or heard before the collision happend?
Describe what you saw before the impact.
Did an airbag deploy in the Injured Person's car?* Was the car that the Injured Person was in, was it working well at the time of the crash?* Did the car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Describe the mechanical problems with the car.*
Weather Conditions were? Road Conditions Was alcohol or drug use any part of this accident?* Was anyone intoxicated during the accident?
What role did alcohol or drugs have in this accident*
Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Do you believe the Injured Person was partially at fault for this accident? What did the Injured Person do wrong that may have contributed to the accident?*
Where was the first point of impact on your vehicle Right before the impact was your vehicle: How many seconds were you at a full stop before being hit from behind?* Where was the first point of impact on the at fault vehicle Describe what happened that caused the accident.*
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the At Fault Driver, Person or Company do that makes you feel they were at fault?*
What specifically did the at fault person do? Why are they negligent?
Did you hear the at fault person say anything about the crash? No, after the crash I never heard the at fault person say anything. Yes, after the collision I heard the at fault person talking.
We want to know what admissions they may have made where they admitted fault in some way.
The At Fault driver made these statements or admissions to Who were the admissions made to?
The at fault person said the following*
Admissions like, I did not see you. It is all my fault. I missed my turn. I don't know what happened. My brakes have been bad for a while.
Witness Identification who may be a witness? How many passengers besides the Injured person were in the Injured Persons vehicle?* No one else, the Injured Person was alone. 1 other person was in the car with the Injured Person. 2 other people were in the car with the Injured Person. 3 other people were in the car with the Injured Person. 4 other people or more were in the car with the Injured Person.
The name of the First other person in the vehicle* First Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the First Other person in the Vehicle?* What is the Address of the First Other Person in the Vehicle I believe the First Other Person in the vehicle* The name of the Second other person in the vehicle* First Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the Second Other person in the Vehicle?* What is the Address of the Second Other Person in the Vehicle I believe the Second Other Person in the vehicle* The name of the Third other person in the vehicle* First Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the Third Other person in the Vehicle?* What is the Address of the Third Other Person in the Vehicle I believe the Third Other Person in the vehicle* The name of the Fourth other person in the vehicle* First Last
We are collecting the names of Eye Witnesses, and or Companions to your case.
Do you have the address of the Fourth Other person in the Vehicle?* What is the Address of the Fourth Other Person in the Vehicle I believe the Fourth Other Person in the vehicle* How many Eye Witnesses are you aware of?* None, I know of no eye witnesses. One, I know of one eye witness. Two, I know of two or more eye witnesses
Name of Eye Witness 1* First Last
What is the name of the first eye witness who you have not told us about already?
Name of Eye Witness 2* First Last
What is the name of the second eye witness who you have not told us about already?
How do we get in touch with any eye witness? Phone number, address, anything to help us find and talk with them.*
How can we get in touch with any eye witnesses so we can ask them what they remember about this.
End of ID of people in Clients car / Beginning of description of the Incident Color, make and year of the at fault car
How many people were in the at Fault vehicle?* Just the driver who was alone The at fault driver and 1 other person The at fault driver and 2 other persons The at fault driver and 3 other persons The at fault driver and 4 other persons
Did the police come to the scene of the crash?* Were there any Skid Marks our gouges left in the road?* EVIDENCE Section: Photographs Check all that you have or have access to* Evidence
Do you want us to hire a photographer to take photos of anything? Where is the Car to be photographed?*
Who else may have any photographs or evidence to help prove your case?
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
What other evidence might exist that we should try to obtain to help prove your case? Who has it, what is it, how do we get it?
Tell us about anything else we might want to photograph, or obtain to help prove your case?
End of Evidence and photographs. Beginning of Injuries Did Fire Rescue come to the accident scene? Which Fire Rescue Department came to the scene of the crash?*
Tell us the name of the Fire Rescue department so we can order the records.
What is the name and location of the Hospital you went to?*
Tell us the name of the Fire Rescue department so we can order the records.
Were you admitted to the hospital over night* Did you ever go to a hospital as a result of this car crash?* Check the boxes for all injuries you received from this crash* Describe any and all injuries you relate to this car crash*
What other injuries or physical or psychological problems are you having that you relate to this crash that you have not checked above.
What doctors or health care people have you seen since the crash?*
Please tell us all the doctors, chiropractors, X-ray, MRI facilities that you have been to after this crash. Name, city, location, so that we can order all of your medical records. If you have not seen anyone yet, just type in NONE.
Have you been prescribed any medications?* Injuries
What medications have you been prescribed because of this incident*
Please list the medications that you have been prescribed, the name of the medication, the strength of the medication and where you got the prescription filed. Example: Flexeril, 80mg as needed, filed at CVS pharmacy on Waters Avenue in Tampa. Or, None, if you don't have any prescriptions.
Have you been prescribed medications but have not yet filled the prescription? Why?* Did you know that Pre-Existing Injuries or conditions can make your case worth more money, not less?* What medications were you taking on a regular basis before this incident?*
Were you taking any medications on a regular basis, such as for a heart condition, or arthritis, blood pressure, diabetes, anything at all. If none, just type in NONE.
Check the boxes for Prior Injuries you have sought treatment for BEFORE this incident* Describe your prior treatment, Who, What When and Where*
We may want to order these records so that we can make sure your treating doctors know about your prior conditions so they can factor them into your health care plan.
List all hospitals you have been in over the past 10 years*
Please tell us each and every hospital you have been seen in over the past 10 years. Including short visits like an Emergency room and released, to long term admission as a patient.
Prior Claims where you sought money from an accident?* Have you ever made any sort of claim before this one? Like workers compensation, car accident, slip and fall, dog bite, class action claim where you were a party?
Tell us about all of your prior claims.*
We need to know about any and all claims you may have had so we can get those records and let your doctors know about your prior injuries and claims.
Prior Chiropractic Care* Have you ever seen a chiropractor, even for one visit before this incident?
What Chiropractors have you seen and what address can we request your records?*
We need the name, address and approximate date that you saw chiropractors before this accident. Also, it may be a good idea for you to return to them to be seen as a Before and After Doctor to help prove your case.
Have you ever had prior psychiatric or psychological care or counseling?* Have you ever seen a psychiatrist, psychologist, or been baker acted before this incident?
What psychiatrists or psychologists have you seen and what address can we request your records?*
We need the name, address and approximate date that you saw any mental health professionals before this accident.
Have you ever had a Workers Compensation Claim?* Tell us about your Workers Compensation Claim(s)*
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Has any doctor taken you off of work because of your injuries in this car crash? Have you been given a work disability slip from anyone because of your injuries from this car crash?
How much work have you missed, or will you miss?
Help us figure out how much work you will miss because of your injuries from this incident. You can say in hours, days, weeks or years.
Which doctor specifically wrote a work restriction for you?
Please give us the name and location of the doctor that has taken you off of work. We need to order your records
What is your best estimate of how much money you will lose (going forward only) as a result of your work restrictions.
What is your estimated Lost wages (in the past only) so far?
Please calculate as best you can what amount of money you have lost so far as a result of this crash?
Beginning of Clients UM and Other Insurance coverage What is the name of your/injured person's car insurance company that was in effect on the date of this accident?*
What is your/injured person's insurance Policy Number?
End of UM and Other Insurance coverage Beginning of PIP Questions for the Injured Person At the time of the crash did the Injured Person own any car or any 4 wheel vehicles? Did you own any 4 wheel motorized vehicles at the time of the crash? If so, your insurance will provide PIP coverage for this car accident.
Was the Injured Person the owner of the vehicle they were in at the time of the crash?* Was the Car or other 4 wheeled vehicle that was owned by the Injured Person, Insured?* End of PIP beginning of At Fault Insurance This is where we start recording that At Fault Insurance Company information.
Which Insurance Companies have contacted you so far?* First Name of At Fault Driver*
First Name of the At Fault Driver.
Middle Name of At Fault Driver
Middle Name
Last Name of At Fault Driver*
Last Name of the At Fault Driver.
Suffix of the At Fault Driver
For example, Jr., III, Esq.
Address of the At Fault Driver Date of Birth of the At Fault Driver At Fault Drivers License Number
Who is the At Fault Driver's Insurance Company
Name of the At Fault Insurance Company
The owner of the vheicle that was at fault is:* Salutation for Owner of the At Fault Vehicle Mr. Mrs. Ms. Dr.
First Name of the Owner of the At Fault Vehicle
First Name of the At Fault vehicle OWNER. If the owner is a company, just enter the name of the company that owned the vehicle that caused injuries.
Middle Name of the Owner of the At Fault Vehicle
Middle Name
Last Name of the Owner of the At Fault Vehicle
Last Name of the At Fault Driver.
Suffix of the Owner of the At Fault Vehicle
For example, Jr., III, Esq.
Address of Owner of the At Fault Vehicle Owner's Insurance Company Claim Number
When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Do you believe the at fault driver was working or running an errand for someone else? Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information Health Insurance Yes or No* Do you have any type of Health Insurance?
Name of your Health Insurance Company
What is your Health Insurance Policy Number
Has Health Insurance paid any of your bills?* Date This date is on your health insurance card and it tell us when your coverage first began.
Heatlh Insurance Information, What is the contact information for your Health Insurance
Medicare Yes or No* Do you have any type of Medicare Insurance or supplements? Medicare is generally for people over the age of 65, or if the person is on Social Security Disability.
What parts of Medicare do you have, check all that apply* Name of your Medicare Insurance Company for Part A*
What is the name of Part A
What is your Medicare Part A Policy Number
We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part A paid any of the bills related to this incident?* We need to know if medicare part A has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part A Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part B*
What is the name of Part B Medicare Insurance Company
What is your Medicare Part B Policy Number
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part B paid any of the bills related to this incident?* We need to know if medicare part B has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part B Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part C*
What is the name of Part C Medicare Insurance Company
What is your Medicare Part C Policy Number
We need to know your Medicare Part C Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part C paid any of the bills related to this incident?* We need to know if medicare part C has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part C Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Name of your Medicare Insurance Company for Part D*
What is the name of Part D Medicare Insurance Company
What is your Medicare Part D Policy Number
We need to know your Medicare Part D Policy Number to find out what medical bills they may have paid relating to this loss
Has Medicare Part D paid any of the bills related to this incident?* We need to know if medicare part D has paid any money to help with your care as a result of this incident?
Effective Date of your Medicare Part D Insurance This date is on your Medicare insurance card and it tell us when your coverage first began.
Medicare Information, What is the contact information for your Medicare*
Do you (injured person) have Medicaid? Yes or No* Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
Name of your Medicaid Insurance Company*
What is your Medicaid Policy Number
We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
Effective Date of your Medicaid Insurance This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Medicaid paid any of the bills related to this incident?* We need to know if Medicaid has paid any money to help with your care as a result of this incident? Medicaid is only available to poor people, not related to age.
Do you (injured person) have Wellcare? Yes or No* Wellcare is available to children and adults of low income, and may not have Medicare Parts A, B or C. We need to know what bills if any Wellcare has paid.
Name of your Wellcare Insurance Company*
It might be called just Wellcare, and it may be managed by another company. We need the company name.
What is your Wellcare Policy Number
Effective Date of your Wellcare This date is on your Medicade insurance card and it tell us when your coverage first began.
Has Wellcare paid any of the bills related to this incident?* We need to know if Wellcare has paid any money to help with your care as a result of this incident? Wellcare is only available to poor people, not related to age.
Do you have any sort of Disability Insurance* If you have any disability insurance that may pay you benefits please let us know about them.
Name of your Disability Insurance Company*
Has your Disability Insurance made any payments to you* Did you receive any payments for short term or long term disability? If so, we need to contact your disability insurance companies to know what their lien is.
Notes regarding Insurance-Medicare-Medicade or any other Collateral Source
Any notes about any sort of collateral source, which is some other company paying any sort of related bills for lost wages or medical treatments. AFLAC would be included here as well. Get copies of any insurance cards
End of Health Insurance Beginning of Property Damage MVA Is there a claim for Property Damage to your vehicle?* What Year is your vehicle
What kind of vehicle do you have
What kind of car was damaged in this crash?
What color is your vehicle
What color is your car
Can your car be fixed or do you think it is a total loss? Was your vehicle towed from the scene? Where is your car now? Is it still accruing storage charges?
Is your car or bike still accruing storage charges?
End of Property Damage MVA Recorded Statements: Have you given anyone a Recorded Statement? Who did you give a Recorded Statement to?*
We want copies of any recorded statement you may have made, or any court appearance you have made. Please tell us when you gave the recording and to whom?
Beginning of Client Assessment and lifestyle Marital Status* Single Married Divorced Widowed Separated and not divorced
Name of Spouse, Ex, or Partner* First Last
How many Children do you have? Have you filed your income tax returns in the past? Do you have copies of your income tax returns? What is the name of the person or company that prepared your tax returns? First Last
What is the highest level of education that you have achieved Some High School GED High School diploma Some college AA or AS degree Bachelors Degree Masters Degree Doctorate Degree Medical Degree
Have you ever been in the military? Were you honorably discharged from the military?* Have you ever had your drivers license suspended or revoked?* Have you ever been arrested?* Why, when and what were you arrested for?*
Please tell us about any and all arrests
Have you ever been convicted of a felony* How many Felony Convictions, what year, what state and county*
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Have you ever been convicted of a Misdemeanor involving theft, false statments or dishonesty shop lifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
How many Misdemeanor Convictions, what year, what state and county*
We need to make certain that we know exactly how many counts you have been convicted of, and we need to order your record to make sure that the answer is 100% correct to avoid a lot of other problems.
Are you thinking about filing for Bankruptcy now or in the future? Filing Bankruptcy may mess up your injury case, but if we know about your filing for bankruptcy before you file, it will help you recover the money, rather than your creditors.
Have you ever hired a lawyer before this claim? Prior Lawyers Names, Address and reasons you hired them.
Please let us know the names, addresses and types of prior injury claim attorneys, workers compensation attorneys or any other notes that may help us with your case. What is the status of their representation of you now?
Have you consulted with other attorneys about this case? No, Jebaily Law Firm, P.A. is the first attorney I have consulted with Yes, I have spoken to other lawyers but not hired them Yes, I am currently represented by another attorney Yes, I have hired other attorneys but they are not my attorney now
We would like to know if you have sought legal representation before calling us?
If you have an attorney already, why are you calling us? The reason I am seeking a second opinion or unhappy with my lawyers is: Before hiring your attorney you have now who you are considering firing, how many other attorneys have you hired for this claim? None other, that the one I have now 1 attorney before the one I have now 2 attorneys before the one I have now 3 or more attorneys before the one I have now
We need to collect all of your records and often times the first or second attorney has some investigative records that we might need to help prove your case.
What is the name of the first attorney you hired before the one you are about to fire? First Last
What is the address of the first attorney you hired What is the name of the Second attorney you hired before the one you are about to fire? First Last
What is the address of the second attorney you hired What is the name of the Third attorney you hired before the one you are about to fire? First Last
What is the address of the Third attorney you hired Do you have any other Pending Injury Claims that are going now? Are you bringing any other personal injury claims other than this one?
My other claim is: A previous car accident A slip and fall or trip and fall claim A medical malpractice case A pharmacy mistake claim A bicycle accident claim A pedestrian claim A motorcycle claim A trucking accident claim A products liability claim A negligent security claim Some other type of claim
Do you have any other pending pclaims going on now?
What is the name of your attorney handling the other pending claim? First Last
What is the address of the attorney handling your other pending claim? Is there anything else you think we should know about you or your claim that has not been covered above?
Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.
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