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Your Name:________________________________
Home address:________________________________
Telephone Numbers:
Home:________________________________
Work:________________________________
Fax:________________________________
Cell:________________________________
Pager:________________________________
Other:________________________________
E-mail address:________________________________
Date of Birth:________________________________
Social Security Number:________________________________
S.C. Drivers License Number:________________________________
Marital Status married, single, or divorced
Name of Spouse:________________________________
How long have you been married?________________________________
Occupation of spouse:________________________________
Your Occupation:________________________________
Employer:________________________________
Supervisor:________________________________
Length of employment:________________________________
Wage/rate of pay:________________________________
Facts of your case what happened?______________________
________________________________
________________________________
________________________________
Date of accident:_________________________________
Location of accident:________________________________
Did you miss time from work as a result of this accident? (yes/no)
If yes, how long?________________________________
Have you consulted any other attorney about this matter? (yes/no)
If yes, which attorney and when?________________________________
Have you ever sued anyone before? (yes/no)
If yes, when and for what reason?________________________________
Please list any witnesses to this accident:
1.________________________________
2.________________________________
3.________________________________
Were you injured in this accident? (yes/no)
If yes, what parts of your body were injured:________________
________________________________
If you were injured, list EMS, doctors and hospitals from whom you received treatment:__________________________________________________________
________________________________
________________________________
Have you been medically released? (yes/no)
If yes, when?________________________________
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