Kevin Chaffin Law Offices in Ventura
   
 

Select your type of case and confidentially submit information for immediate attorney review and response.

Wrongful Death
Wrongful Termination
Sexual Harassment
Hostile Work Environment
Failure to Pay Wages
Overtime and Salary Claims
Retaliation and Whistleblower
Discrimination
Medical Malpractice
Elder Abuse & Nursing Homes
Train Accidents
Car & Motorcycle Accidents
Personal Injury

Home | Ventura County, California - Ph 805-650-8200 - info@chaffinlaw.com | About Us

Car & Motorcycle Accidents Questionare

PLEASE NOTE:
This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client's case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work product doctrine. It is very important that you be completely truthful, accurate and complete in answering the following questions. The defendant in this case will likely obtain all relevant records about you. Therefore, it is crucial that we are aware of all information, including information you may believe will damage your case, in order to best represent you. If we decline to take your case, it does not mean you do not have a case. Therefore, if we decline your case you should contact another attorney. Most of our clients are employees or injured persons. If you are an employer, or you are concerned you might be sued by someone else, do not complete a questionnaire. Instead, you must first contact our office by telephone.

GENERAL BACKGROUND INFORMATION
1 What is your name?

2 What is your age?

3 What is your mobile cell phone number?

4 What is your home phone number?

5 What is your e-mail address?

6 What is your street address?

City

State

Zip Code

7 What is your Social Security Number?

8 What is your California Drivers License Number?

9 What is your Date of Birth?

GENERAL CASE INFORMATION
10 Date of Incident/Accident Causing Injury?
(This is very important information. Please describe in detail if you are in doubt as to the date of the accident/incident giving rise to liability. Your ability to recover damages may be limited by a statute of limitations - if you fail to file a claim within the appropriate time restriction, your right to recover may be forever lost and barred.)
11 Where did the accident/incident take place? (City, County, State, Street Address)


13 Describe how the accident/incident occurred:


13 Was there a police report or written report generated? If yes, list the report number and agency that wrote the report.

14 Were there any witnesses to the accident/incident? If yes, list their names, addresses, telephone numbers and descriptions.

15 List all parties that were involved in the accident/incident: (For example, the other driver, the manufacturer, the store or property location, the medical care provider, the owner of the dog, etc.)

16 Who do you believe was at fault for the accident/incident? (For each party named, describe how they were at fault.)

INJURY INFORMATION
17 What type of injury did you sustain?


18 Describe your injuries in detail.

19 Have you ever suffered any type of similar injury before? If yes, describe in detail.

20 Have you ever had a claim, case or settlement for any type of claim arising from Negligence, Automobile Accident, Motorcycle Accident, Bicycle Accident, Pedestrian Accident, Slip-n-Fall Accident, Products Liability, Assault & Battery, Wrongful Death, Medical Malpractice, Dog Bite, or Other (Please Describe)

21 Please list the name, address, telephone number of every medical care provider you have seen for your injury: (Including ambulance, emergency room, x-ray or diagnostic imaging, family or primary doctor, specialists, physical therapists, chiropractors, psychologist, psychiatrist, or other)

22 Chronology: Please provide the Date of the accident/incident, the date you first sought medical care, the date of each subsequent visit for medical care, and the date of any other event or fact that you consider to be significant:

23 List the name, address, telephone number and injuries of anyone else that was injured in the accident/incident:

24 Describe any documents that you believe support your case?

INSURANCE INFORMATION
25 Did you have automobile insurance at the time of the accident/incident?

If yes, list your Insurance Company, Policy Number, Claim Number, Insurance Agent's Name/Address/Phone

26 Were you living with anyone who had automobile insurance at the time of the accident/incident?

If yes, list their name, Insurance Company, Policy Number, Claim Number, Insurance Agent's Name/Address/Phone

27 Did you have homeowners/renters insurance at the time of the accident/incident?

If yes, list your Insurance Company, Policy Number, Claim Number, Insurance Agent's Name/Address/Phone

28 Were you living with anyone who had homeowners/renters insurance at the time of the accident/incident?

If yes, list your Insurance Company, Policy Number, Claim Number, Insurance Agent's Name/Address/Phone?

29 Did any other party involved in the accident/incident have insurance?

If yes, provide their name, their Insurance Company, their Policy Number, their Claim Number, and any other information you know regarding their insurance.

DAMAGES
30 Please list all medical bills you have incurred to date relating to the incident: (It does not matter if insurance paid the bills, list them)

31 Describe all property loss resulting from the accident/incident (damage to your vehicle, your possessions, etc):

32 Describe all financial loss resulting from the accident/incident (medical bills, lost wages, lost income, lost opportunities, etc): If you have any doubt as to whether or not something is a loss that may be recovered, list it):

33 Were you working at the time of the accident/incident?

If yes, please list your employer, supervisor, job title. If you have lost any wages, used any vacation or sick time, or suffered any type of employment related loss please describe:

PRIOR CIVIL OR CRIMINAL LITIGATION OR CLAIMS
34 Have you ever filed a lawsuit before or have you ever been sued before

If so, please explain:

35 Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future?

If so, please state the date you filed and the result, (or state the date you are planning on filing bankruptcy. (****Note if you are planning on filing bankruptcy anytime soon do not sign or file any bankruptcy documents without consulting with this office first, as filing a bankruptcy action could result in the termination of your lawsuit****)

36 Have you ever been arrested?

If so, please state the date, the charge/s and whether you were convicted.
37 Have you ever filed a workers compensation claim for any injuries sustained at work?

If so, state the date of complaint and the result?

 
Chaffin Law Office - P.O. Box 3076, Ventura, California 93006 - Phone 805-650-8200 - email: info@chaffinlaw.com