Personal Injury Client Information Sheet

Thank you for choosing The Chivis Law Firm. In order for us to assist you better, please take a few minutes to review and complete the following information sheet.

"*" indicates required fields

How did you hear about The Chivis Law Firm?

YOUR INFORMATION

Name:*

DOB:

Email:

Social Security Number:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Mobile:

Are you Married?

YES

Spouse’s Name:

Spouse's Contact Number:

Alternate Contact Name:

Alternate Contact Number:

ACCIDENT INFORMATION

Date of Accident:

Location of Accident:

1. Were police at the scene?

YES

2.Was a police report made?

YES

Report#

Describe how the accident occurred:

Do you have photographs of the damage to your car?

YES

Do you have photographs of the damage to any other car?

YES

Do you have photographs of your injuries?

YES

Do you have photographs of the accident scene?

YES

If no, please take a photo of your vehicle’s damage and email it to our office at: information@chivislaw.com

WITNESSES

1. Name:

Phone Number:

Address:

City:

State:

Zip:

2. Name:

Phone Number:

Address:

City:

State:

Zip:

3. Name:

Phone Number:

Address:

City:

State:

Zip:

4. Name:

Phone Number:

Address:

City:

State:

Zip:

MEDICAL INFORMATION

Were you taken by EMS?

YES

Did you go to the emergency room?

YES

If so, Date:

Name and Location of Hospital:

Did you visit any other medical provider to treat your injuries? If so, list name and contact info:

Which part(s) of your body are injured?

Neck

Shoulder L/R

Arm L/R

Back Upper/Lower

Leg L/R

Knee L/R

Other (please list)

Do you need further treatment?

YES

Do you have Health Insurance?

YES

Company Name:

Hidden

LOR sent

LOR sent (administrative use only)

Plan#:

Group#:

Did you use health insurance for payment of your medical treatment?

YES

If yes, which health provider?

Do you have? Medicare

YES

Group#:

Do you have? Medicaid

YES

Group#:

If your child was injured in the accident, is your child covered by Medicaid?

YES

Have you been injured in the past?

YES

If yes, please explain:

Hidden

MEDICAL BILLING AND RECORD COLLECTION (Admin Use Only)

Medical Provider’s Name	LOR Sent & Date	Sent by	Billing recorded in Calc.	Correspondence and dates
		Email Fax Mail
		Email Fax Mail
		Email Fax Mail
		Email Fax Mail
		Email Fax Mail
		Email Fax Mail
		Email Fax Mail

YOUR VEHICLE AND INSURANCE INFORMATION

Make and Model:

Year:

Is your vehicle drivable?

YES

Do you have an estimate for your vehicles damages?

YES

Has your vehicle been repaired?

YES

Insurance Company:

Policy#:

1. Do you have UM/UIM Coverage?

YES

2. Do you have PIP or Med Pay Coverage?

YES

Claim# (if applicable):

YOUR EMPLOYMENT INFORMATION

Your Employer:

Occupation:

Have you missed work due to your injuries?

YES

AT FAULT DRIVER’S INFORMATION, VEHICLE AND INSURANCE INFORMATION

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Make and Model:

Year:

Was their vehicle drivable?

YES

Have you been contacted by the other drivers’s insurance company?

YES

Have you given the opposing Insurance company a Statement?

YES

Has liability been accepted by opposing Insurance?

YES

Hidden

LOR sent

LOR sent (administrative use only)

Insurance Co:

Hidden

Declaration Page Received

Declarations page received

Adjuster’s Name:

Phone#:

Policy#:

Claim#:

Reminder: Please send any and all documents related to incident including correspondence, bills, photos, a copy of your license and health insurance card if applicable to information@chivislaw.com

Hidden

Demand Letter Date:

Hidden

Petition File Date:

Hidden

FIRM NOTES LOG ( Admin Use Only)

Date

Name of Firm Rep

Note

Top Tier Representation

Efficient, Productive, Reliable, and a successful outcome. Thank you Chivis Law Firm. Top Tier Representation.

Mencho Garcia

Above and Beyond

The Chivis Law Firm helped us and kept us informed every step of the way. Any and all questions were answered clearly and their patience and professionalism is absolutely above and beyond. We definitely made a great choice by hiring them in our time of need.

reydoggatron01

Outstanding Firm

Mr. Chivis and his team were an outstanding firm to help guide us through an automobile accident. From the initial conversation I felt comfortable with the process. His team was always in contact with us and assured us that the process was moving forward. Two years went by and our case was finally settled. Even though we live in Houston…Mr Chivis and his team were able to assist us from San Antonio. Thank you Mr. Chivis and Team!

David Sanchez

Disclaimer: The information on this website is for general information purposes only. Nothing on this site should be taken as legal advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, an attorney-client relationship.

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