Hall Law Firm
5037 Veterans Memorial Blvd, Suite 1D
Metairie, LA 70006
(504) 321-1246
Personal Injury Intake
(Auto Accident)
Thank you so much for contacting Hall Law Firm! Please read the privacy policy below, and then fill out this form to the best of your knowledge, in its entirety (for all applicable sections) prior to our consultation.
Privacy Policy
All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.
Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.
Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:
initial service
in court orders
in required reports or other documents filed with the State
If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!
PERSONAL INFORMATION
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Preferred Contact Method
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Email
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No Preference
Gender
Male
Female
Social Security #
Driver's License #
Marital Status:
Single
Married
Spouse or Partner's Full Name:
Divorced
Widow(er)
Do you have any military service?
Yes
Dates of Service:
Branch of Military:
Any Military Service Related Injuries? (describe):
Rank/Paygrade:
Were you dishonorably discharged?
No
How were you referred to our law firm?
Friend or family member
Input the person's full name:
Another attorney
Input the attorney's full name:
Online search or lawyer directory website
Input the name of the website:
For example, "Avvo", "Findlaw", "Facebook", "Google", or website address, etc.
Billboard, bus stop, phone book, newspaper, or other physical advertisement
Where was the ad located?
Radio or TV advertisement
What radio or TV station?
Bar Association
Which Bar Association?
Other
Please explain how you found us:
ACCIDENT INFORMATION
IF APPLICABLE
Is this an auto accident?
Yes
No
What type of accident?
Were you a Driver, Passenger, or Pedestrian?
Driver
Passenger
Please Give the Driver's Full Name
Driver's Insurance Company
Pedestrian
How many total vehicles were involved in the accident?
2
3
4 or more
Date of Incident
Time of Incident
also include AM or PM
City of Incident
Parish of Incident
Road/Intersection
(if applicable)
Were the police called to the scene?
Yes
Police Details
(Police Department Name, Officer's Name, Other Details)
No
Did the police show up at the scene?
Yes
No
Was an accident or incident report filed?
Yes
Report Number
Report Details
No
Unknown
If the a Police Officer showed up at the scene and DID NOT file an accident report, did they give an explanation of why they would not file the report
Yes
Please state the reason provided
No
Describe How the Incident Occurred
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YOUR VEHICLE INFORMATION
(or the vehicle you were driving) TO THE EXTENT KNOWN / APPLICABLE
What is the make, model, and year of your car?
or car that you were driving / a passenger in (if applicable)
What is the license plate number of your car?
What was the damage to your car?
How did you leave the scene of the accident?
Did you have to rent a car?
Yes
Give the name of the company and the amount of the rental
No
OTHER PARTY(IES), AND VEHICLES, INVOLVED IN THE ACCIDENT
If KNOWN / APPLICABLE
OTHER VEHICLE #1
Please complete to the best of your current knowledge.
IF THERE WERE NO MORE THAN TWO (2) VEHICLES INVOLVED IN THE ACCIDENT, PLEASE SKIP THE FOLLOWING "OTHER VEHICLE" SECTION.
What is the make, model, and year of Other Driver #1's vehicle?
What was the license plate number of other Driver #1's vehicle?
What was the damage to that car?
Who was the Owner of that car?
Name of the Other Driver #1
Other Driver #1's Address
Other Driver #1's Phone Number
Other Driver #1's Job / Occupation
Other Driver #1's Age
Other Driver #1's Insurance Company
If Other Driver #1 was not the owner of the vehicle he/she was driving, please also state the insurance company with whom the owner had coverage.
Other Driver #1's Insurance Adjuster
Other Driver #1's Insurance Coverage
(if known)
Give your observations about Other Driver #1 as a person.
Did other Driver #1 have any passengers in his/her vehicle with him/her at the time of the accident?
Yes
Please list the number of passengers, and any information you know about them (such as age/gender/relationship to Driver, etc.)
No
How did Other Driver #1's car leave the scene?
Was it towed? If so, state by whom and where taken? (if known)
OTHER VEHICLE #2
Please complete to the best of your current knowledge.
What is the make, model, and year of Other Driver #2's vehicle?
What was the license plate number of other Driver #2's vehicle?
What was the damage to that car?
Who was the Owner of that car?
Name of the Other Driver #2
Other Driver #2's Address
Other Driver #2's Phone Number
Other Driver #2's Job / Occupation
Other Driver #2's Age
Other Driver #2's Insurance Company
If Other Driver #2 was not the owner of the vehicle he/she was driving, please also state the insurance company with whom the owner had coverage.
Other Driver #2's Insurance Adjuster
Other Driver #2's Insurance Coverage
Give your observations about Other Driver #2 as a person.
Did other Driver #2 have any passengers in his/her vehicle with him/her at the time of the accident?
Yes
Please list the number of passengers, and any information you know about them (such as age/gender/relationship to Driver, etc.)
No
How did Other Driver #2's car leave the scene?
Was it towed? If so, state by whom and where taken? (if known)
Describe the Point of Impact for Each Auto
How far did the cars travel after impact?
Position of Vehicles After Impact
PASSENGERS IN YOUR VEHICLE
IF APPLICABLE
IF YOU HAD PASSENGERS WITH YOU IN YOUR VEHICLE AT THE TIME OF THE ACCIDENT, PLEASE FILL OUT THE FOLLOWING:
Passenger #1
If applicable, please select "Fill out passenger information" and complete the following information.
Fill out passenger information
Name
Address
Age
Seated
Injuries
Not Applicable
Passenger #2
If applicable, please select "Fill out passenger information" and complete the following information.
Fill out passenger information
Name
Address
Age
Seated
Injuries
Not Applicable
Passenger #3
If applicable, please select "Fill out passenger information" and complete the following information.
Fill out passenger information
Name
Address
Age
Seated
Injuries
Not Applicable
Passenger #4
If applicable, please select "Fill out passenger information" and complete the following information.
Fill out passenger information
Name
Address
Age
Seated
Injuries
Not Applicable
Additional Passengers or Information
WITNESSES
IF APPLICABLE
Witness #1
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Seat or Location
Injuries
Not Applicable
Witness #2
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Seat or Location
Injuries
Not Applicable
Witness #3
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Seat or Location
Injuries
Not Applicable
Witness #4
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Seat or Location
Injuries
Not Applicable
Additional Witnesses or Information
STATEMENTS MADE
Have you told any police officer, investigator, insurance adjuster or any other person about the collision? Please list each person and the entire substance of your statement.
YOUR AUTOMOBILE INSURANCE INFORMATION
IF APPLICABLE
Name of Your Auto Insurance Carrier
Name of Policy Holder
Policy Number
Agent / Adjuster
Adjuster/Agent's Telephone Number
Claim Number
(if known / you have filed a claim with your insurance company regarding the accident)
Type of Coverage
Did you (and/or the owner of the vehicle you were in) have Uninsured/Underinsured Motorist (UM) Coverage?
Yes
UM Coverage Limits
No
INJURIES
Please describe any and all aches, complaints, discomforts and disabilities, as a result of injuries related to the subject accident, in detail.
Check symptoms you have noticed since the accident
select all that apply
Upset Stomach
Fainting
Increased sensitivity to light
Pins & needles in legs
Ears ringing
Shortness of breath
Dizziness
Sleeping problem
Back pain
Loss of smell
Loss of memory
Feet cold
Buzzing in ears
Fatigue
Head seems too heavy
Numbness in fingers
Cold sweats
Tension
Muscle Pain
Other Numbness
Headache
Neck pain
Hands cold
Loss of balance
Depression
Pins & needles in arms
Nervousness
Numbness in toes
Chest pain
Neck stiff
Problems Sleeping
Other (please describe below)
Did you go to the hospital?
Yes
Name of Hospital
No
Did you go by ambulance?
Yes
Name of Ambulance Service
No
Did they take x-rays?
Yes
No
Have you seen a doctor since the date of the accident, other than at the emergency room?
Yes
If yes, please list all doctors/treating providers
name, address and telephone number
No
PRIOR INJURY HISTORY
Have you had any accidents or injuries before this accident?
Injury #1
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Nature of Injuries
Injury Treated by
Not Applicable
Injury #2
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Nature of Injuries
Injury Treated by
Not Applicable
Injury #3
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Nature of Injuries
Injury Treated by
Not Applicable
Injury #4
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Nature of Injuries
Injury Treated by
Not Applicable
Additional Past Injury Information
LOSS OF EARNINGS
If you anticipate loss of earnings due to accident related injuries, please complete the following:
Are you currently employed?
Yes
Employer:
Length of Time with Current Employer:
Job Title:
Employer Address:
No
Are you paid hourly or salary?
Hourly
Rate of Pay
$____per hour
Salary
Yearly Salary
How many hours do you normally work per week?
Were you working at the time of the accident?
Yes
No
Have you missed any work as a result of the accident?
Yes
Amount of time missed
No
Do you anticipate missing any/any more work as a result of the accident?
Yes
No
Do you intend on making a claim for lost wages?
Yes
No
ADDITIONAL INFORMATION
Any additional Information you think would be helpful?
E-ACKNOWLEDGEMENT
Please acknowledge that you have read and hereby accept the above privacy policy regarding use of personal information, and that submission of this form does not create an attorney client relationship, by typing your full legal name below
THANK YOU
If you have completed the form, please click
SUBMIT
.
If you do not already have your free consultation scheduled, someone will reach out to you shortly to schedule same (via your preferred contact method as indicated in Question 3).
If there were Four (4) or more vehicles involved in the accident, you will receive a supplemental form with additional "Other Vehicle" sections to complete.
Please feel free to contact us by phone call or text, at 504-321-1246; or by email at hall.lawfirm@outlook.com if you have any questions.