PI Intake Form - Foster Graham Milstein & Calisher

Our unified team of dedicated and experienced attorneys can help.

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Who may we thank for referring you to our office?
Who was injured in this accident?
Date of birth of injured
MM slash DD slash YYYY
Last 4 digits of SSN
Date of injury
MM slash DD slash YYYY
Location of injury
Include address and name of establishment if relevant
Describe what happened that caused injury
List the names, phone numbers and addresses of any witnesses to the accident.
If you do not know all of this information provide what you know.
What are your injuries and what is your current condition
List your doctors/physical therapists etc. that you have treated with as it relates to this case.
Please include your doctors’ names, addresses and phone numbers, as well as why you are seeing this doctor.
List the name, address and phone numbers of the person(s) or company that you believe caused the injuries
List their insurance company, phone number, address and claim number, if you know it
List your automobile insurance company information (company, policy number, address and phone) IF this involves your injury in an automobile or similar accident
List your health insurance company information AND, if applicable, disability policy information (company, policy number, address and phone) IF you are utilizing your health insurance to care for your injuries
Is this health insurance privately purchased OR is it provided in whole or in part through your employer or your spouse’s employer?
How much time have you missed from your job, and are you utilizing any temporary disability insurance during your recovery?
How much income have you lost? How much do you expect to lose? And how is this lost income determined?
Please list all out of pocket losses you have incurred as a result of this injury.
Please provide any other information you believe will assist our office in resolving this matter.
Name of Police Agency that responded to incident.
Name of Ambulance company that transported you.
Comments
This field is for validation purposes and should be left unchanged.