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Client Information:

Name:
Referral Source:
Are You Currently Represented?
Name of Attorney:
Have You Contacted Any Other Attorneys About This Case?
Have You Ever Been Convicted of a Felony
or a Crime Involving Truth/Dishonesty?
Have You Filed for Bankruptcy Since the Injury Occurred?
What Type?
Please List Any Traffic Citations:
Social Security Number (Optional):
Date of Birth:
Driver's License Number:
Insurance Company:
Policy Number:
Claim Number:
Personal Hospitalization Insurance:
Marital Status:
How Many Dependents Do You Have:
Education:
Current Address:
Street:
City:
State:
Zip Code:
Is This Also Your Permanent Address?
Primary Telephone Number:
Best Time To Contact You:

Other Contacts:

With Whom Do You Reside? (List With Commas)

Emergency Contact Information:
Name:
Street:
City:
State:
Zip Code:
Telephone Number:

Current Employer:
Employed Since:
Rate of Pay:
Disability Status:
Supervisor's Contact Information:
Name:
Street:
City:
State:
Zip Code:
Telephone Number:

The Accident:

Date of Accident:
Time of Accident (If Known):
Others Present (List):
Others Injured(List):
Role in Collision:
How Did You Leave the Scene:
Police Report Filed:
Other Party's Percentage of Fault:
Location of Accident (City/County):
Type of Accident (Check all that apply): Rear-End Intersection Multi-Vehicle Scope of Employment
Other (please specify)
Make and Model of Car:
Collision Coverage Deductible:
Other Property Damage:
Tickets Issued:

Injuries and Treatment:

Injuries, Complaints, and Limitations:
Treatment (Include Doctor Ordered Limitations):
Prior Injuries or Claims:
Prior Related or Similar Symptoms:
Present Diseases or Illnesses:

Defendant Information:

Name:
Date of Birth:
Physical Description:
Make and Model of Vehicle:
Driver's License Number:
Insurance Company:
Policy Number:
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Additional Information

Visit our information centers to learn more about the following topics:

  • Motor Vehicle Accidents
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Office Locations

Edina Office
6500 France Avenue South
Edina, Minnesota 55435

Local: (952) 236-4298
Toll Free: (866) 531-2705
Fax: (952) 920-6869

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