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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 Occured?
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 specifty)
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 Releated 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:

For over 43 years, the law firm of Milavetz, Gallop & Milavetz has been confidently serving clients from their offices in Minnesota, including individuals in the areas of Minneapolis, St. Paul, Edina, Coon Rapids, Brooklyn Center, Roseville, St. Cloud, the entire Twin Cities metro area, western Wisconsin including Hudson, Menomonie, and Eau Claire, and all of the surrounding areas.

Five Convenient Offices

Edina Office
6500 France Avenue South
Edina, Minnesota 55435
Phone: (952) 920-7777
Fax: (952) 920-6869
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