Colorado Law.com

Client Information Sheet
Wrongful Death-Auto

Personal Information
Full Name: Birthday:
Address: Social Security No.
City: State: Zip Code:
Phone, Work: Home Phone:
Spouse: Name: Work Phone:
Name of person other than your spouse who should always know your whereabouts:
Name: Relationship:
Work Phone: Home Phone:
General Information
Name of deceased: Birthdate:
Date of Death: Do you have a copy of death certificate:
Date of injury (if different from date of death):
Cause of death:
Has an estate been opened:
Location:
Name of personal representative::
Address of personal representative:
Personal representative's relationship to the deceased:
Your relationship to the deceased:
Please list other relatives to the deceased:
Name: Relationship Date of birth
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Are you aware of any other litigation which has been commenced as a result of this claim:
If so, name of person who filed suit:
Address:
Relationship to the deceased:
Accident Information
Accident Date: Time of day:
Location: (please be specific)
How many vehicles were involved?
Vehicle #1 (Your Vehicle):
Drivername:
Address:
Telephone:
Owner of the vehicle:
Address:
Telephone:
Make, model and year: Color:
License Plate Number: State:
Where is the car now:
Do you have a repair estimate?: Amount of estimate:
Do you have photo's of your car?
Passengers:
Name:
Address:
Telephone:
Name:
Address:
Telephone:
Were you wearing a seatbelt?
Vehicle #2: (Driver at Fault)
DriverName:
Address:
Telephone:
Owner of the vehicle:
Address:
Telephone:
Make, model and year: Color:
License Plate Number: State:
Accident Scene
Weather conditions:
Road Conditions: ( wet, dry, snowy, icy, etc.)
How many lanes on the road?
How are the lanes marked: (broken white line, solid yellow lines, etc.)?
Was passing allowed?
Any Traffic signs: (stop, yield, etc.)?
Any Traffic signal:
If so, were they overhead or at the side of the road?
Any construction in the area?
Anything which might have obstructed the view of either driver?
If so describe:
Did any of the vehicles have its lights on?
Did any of the vehicles have any type of defective equipment (bad brakes, broken headlight or taillight)?
How did the accident happen?
Police investigating agency:
City: County (Sheriff)
Statepatrol: Other:
What citations did you receive?
What citations did the other driver receive?
Did the police test anyone for alcohol?
Were there any witnesses to the accident?
Name:
Address:
Medical Information
Were you injured in this incident? Describe:
Were you treated at a hospital immediately following the incident?
Were you taken by ambulance to the hospital?
Name of ambulance service:
Name of hospital:
Address:
Were X-rays taken?
Are you under the care of a Physician now?
List all doctors that have treated you for this incident:
Name:
Address:
Telephone:
Date of last appointment:
Name:
Address:
Telephone:
Date of last appointment:
Name:
Address:
Telephone:
Date of last appointment:
What is the approximate amount of your medical bills?
Have you had any other injuries, either before or after this accident?
Describe:
Loss of Wages
Were you employed at the time of this incident?
Name of employer:
Address:
Occupation:
How long have you worked there?
Hours worked per week: Regular hourly wage:
Overtime per week: Overtime Rate:
Are you working now?
If time lost from work:
Regular hours lost from work:
Overtime hours lost from work:
Total loss of wages to date:
If you are not employed, please identify:
Last employer:
Address:
Last date you worked there:
Insurance Information
Vehicle #1 (your car)
Insurance Company:
Policy holder:
Policy/Claim number
Adjustername:
Address:
Vehicle #2 (Driver at fault)
Insurance Company:
Policy holder:
Policy/Claim number
Adjustername:
Address:
Has anyone from either insurance company contacted you?
When? To whom did you speak?
Did you give a written or recorded statement?
Do you have a copy?
How did you hear about Colorado Law.com:
If TV, what time of day did you see the advertisement:
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