C
olorado
L
aw.com
Client Information Sheet
Wrongful Death-Medical Malpractice
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:
Y or N
Yes
No
Date of injury (if different from date of death):
Cause of death:
Has an estate been opened:
Y or N
Yes
No
Location:
Name of personal representative::
Address of personal representative:
Personal representative's relationship to the deceased:
Your relationship to the deceased:
select one
Spouse
Minor Child
Adult Child
Parent
Please list other relatives to the deceased:
Name:
Relationship:
Date of birth:
is a
select one
Spouse
Minor Child
Adult Child
Parent
is a
select one
Spouse
Minor Child
Adult Child
Parent
is a
select one
Spouse
Minor Child
Adult Child
Parent
is a
select one
Spouse
Minor Child
Adult Child
Parent
is a
select one
Spouse
Minor Child
Adult Child
Parent
is a
select one
Spouse
Minor Child
Adult Child
Parent
Are you aware of any other litigation which has been commenced as a result of this claim:
Y or N
Yes
No
If so, name of person who filed suit:
Address:
Relationship to the deceased:
Description of the substandard care:
Date you discovered the substandard care:
How did you discover the substandard care:
Medical provider at fault:
Name:
Address:
Telephone:
Current treating physician:
Name:
Address:
Telephone:
Injuries suffered because of the substandard care:
List all doctors that have treated you in the past ten years:
Name:
Address:
Telephone:
Description of treatment:
Name:
Address:
Telephone:
Description of treatment:
Name:
Address:
Telephone:
Description of treatment:
Loss of Wages
Were you employed at the time of this incident?
Y or N
Yes
No
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?
Y or N
Yes
No
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
Health insurance company:
Policy holder:
Policy / Claim number:
Adjuster name:
Address:
Have you submitted a claim to the medical provider's insurance company?
Y or N
Yes
No
Has anyone from the medical provider's insurance company contacted you?
Y or N
Yes
No
When?
To Whom did you speak?
Did you give a written or recorded statement?
Y or N
Yes
No
Do you have a copy?
Y or N
Yes
No
How did you hear about Colorado Law.com:
Select one
Yellow Pages
Friend/relative
TV
Other
If TV, what time of day did you see the advertisement:
select a time
morning
afternoon
night
late night
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