Blady Weinreb Law Group LLP
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COMMITMENT-REPUTATION-RESULTS ©
Injury Questionnaire

 

Personal Injury Questionnaire

The following questionnaire is requested for an initial evaluation of an injury claim.  The submission of information is for review only.  BWLG is not agreeing to accept your case by reviewing this questionnaire.  BWLG is not your attorney unless and until a written Retainer Agreement is signed by both you and a member of the firm.

It takes time to review the material submitted and to reply.  If you do not receive a response within 1 week, please accept the non-response as an indication we are unable to accept your case.

The information you provide to us is for the purposes of obtaining advice and therefore we consider the informtion subject to the attorney-client privilege, even prior to us agreeing to accept your case.
Personal Injury Questionnaire

Your Name
Your Address  
      Street (Apartment Number)
      City 
      State
      Zip
E-Mail
Home Phone Number

Cell Phone Number
Name of Person or Buseinss That Caused Your Accident or Injury
Date of Injury
Location of Injury or Accident (Include City)
How Did the Accident Happen? (Include What Caused the Accident or Injury, and Who was at Fault)
Example:  The other driver made an unsafe left turn, other driver ran a red light, etc.
Desribe Your Injury and Damages


Example:  I needed surgery and rehabiliton for ______.  I was earning $___ per month and missed __ months of work.  My car was ________.  I have suffered from continuing effects of the accident, including _____________.
Did the Police Respond to Your Accident?  If, so do You Have a Police Report:

Did You Receive Medical Treatment?  If so, Where?  Do You Have Medical Records?


 

Blady Weinreb Law Group LLP
6310 San Vicente Boulevard, Suite 400
Los Angeles, California 90048
(323) 933-1352
FAX (323) 933-1353

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