Date Format: MM slash DD slash YYYY
What type of case is this?
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
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.
For example, Jr., III, Esq.
Thank you for sharing with us how you found Jebaily Law Firm, P.A.
Please tell us the name of the Attorney who referred you to Jebaily Law Firm, P.A.
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This is the address where we will mail any documents relating to the case.
What is your Facebook web address? Example https://www.facebook.com/jebailylaw
Enter the person's birth date
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
Your First Name. This is where you enter the name of the Injured Person or deceased victim.
Middle Name
Last Name. This is where you enter the name of the Injured Person, child or deceased victim.
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.
Beginning of LIABILITY
Select the State where the Crash happened
Example: the intersection of Dale Mabry and Kennedy Boulevard in Tampa.
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Describe what you saw before the impact.
Did the car have any mechanical problems? Like lights not working, brakes not very good, bald tires.
Was anyone intoxicated during the accident?
Describe what drugs or alcohol was involved, and who was under the influence of drugs or alcohol.
Describe the accident, who did what, where they came from in detail regarding the facts of the negligence.
What specifically did the at fault person do? Why are they negligent?
We want to know what admissions they may have made where they admitted fault in some way.
Who were the admissions made to?
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?
We are collecting the names of Eye Witnesses, and or Companions to your case.
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We are collecting the names of Eye Witnesses, and or Companions to your case.
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We are collecting the names of Eye Witnesses, and or Companions to your case.
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We are collecting the names of Eye Witnesses, and or Companions to your case.
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What is the name of the first eye witness who you have not told us about already?
What is the name of the second eye witness who you have not told us about already?
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
EVIDENCE Section:
Evidence
Please tell us who to contact that may have photographs or evidence we can use to prove your case.
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
Tell us the name of the Fire Rescue department so we can order the records.
Tell us the name of the Fire Rescue department so we can order the records.
What other injuries or physical or psychological problems are you having that you relate to this crash that you have not checked above.
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.
Injuries
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.
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.
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.
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.
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?
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.
Have you ever seen a chiropractor, even for one visit before this incident?
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 seen a psychiatrist, psychologist, or been baker acted before this incident?
We need the name, address and approximate date that you saw any mental health professionals before this accident.
We need the name, address and approximate date that you had a work injury and sought any medical treatment.
Have you been given a work disability slip from anyone because of your injuries from this car crash?
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.
Please give us the name and location of the doctor that has taken you off of work. We need to order your records
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
End of UM and Other Insurance coverage
Beginning of PIP Questions for the Injured Person
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.
End of PIP beginning of At Fault Insurance
This is where we start recording that At Fault Insurance Company information.
First Name of the At Fault Driver.
Middle Name
Last Name of the At Fault Driver.
For example, Jr., III, Esq.
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Name of the At Fault Insurance Company
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
Last Name of the At Fault Driver.
For example, Jr., III, Esq.
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When you spoke to the at fault driver's insurance company did you get a claim number? if no, just type in unknown
Beginning of Medical Bills - Health, Medicare and Medicaid Insurance Information
Do you have any type of Health Insurance?
This date is on your health insurance card and it tell us when your coverage first began.
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 is the name of Part A
We need to know your Medicare Part A Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part A has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part B Medicare Insurance Company
We need to know your Medicare Part B Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part B has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part C Medicare Insurance Company
We need to know your Medicare Part C Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part C has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
What is the name of Part D Medicare Insurance Company
We need to know your Medicare Part D Policy Number to find out what medical bills they may have paid relating to this loss
We need to know if medicare part D has paid any money to help with your care as a result of this incident?
This date is on your Medicare insurance card and it tell us when your coverage first began.
Medicaid is available to children and some adults with low income. We need to know what bills if any Medicaid has paid.
We need to know your Medicais Policy Number to find out what medical bills they may have paid relating to this loss
This date is on your Medicade insurance card and it tell us when your coverage first began.
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.
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.
It might be called just Wellcare, and it may be managed by another company. We need the company name.
This date is on your Medicade insurance card and it tell us when your coverage first began.
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.
If you have any disability insurance that may pay you benefits please let us know about them.
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.
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
What kind of car was damaged in this crash?
What color is your car
Is your car or bike still accruing storage charges?
End of Property Damage MVA
Recorded Statements:
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
Please tell us about any and all arrests
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.
shop lifting, writing a bad check, petty theft are examples of misdemeanors that we need to know about
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.
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.
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?
We would like to know if you have sought legal representation before calling us?
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.
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Are you bringing any other personal injury claims other than this one?
Do you have any other pending pclaims going on now?
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Please share with us any other information that might be remotely important or related to your claim that has not been asked about above.
