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PERSONAL INJURY INTERVIEW SHEET

Being injured is never planned and can cause significant interruption in your life with major implications for you both emotionally and financially.

Please fill out this interview sheet with as much information as possible to inform us of your incident. We will pre-assess your situation based on this information.

PLEASE NOTE: We only accept Personal Injury Interview Sheet submissions if the incident has occurred within the past 18 months as of today's date.

PLAINTIFF:

Full Name:
Email:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Type of Incident:
Date of Incident:
Special Statute of
Limitation or Notice:   
Referred by:

PERSONAL INFORMATION:

DOB:
SIN Number:
MSP Number:
Driver's License No.:  
Marital Status:
Date of Marriage:
Spouse:
Spouse DOB:

CHILDREN:

Name:                      
DOB:
Name:
DOB:
Name:
DOB:

EMPLOYMENT:

Name of Employer:
Type of Work:
Address:
Length of Employment: 
Wage Rate:
Supervisor:
Time Lost from Work:
Total Loss of Wages
or Income:
Education &
Work Background:
Property Damage &
Other Losses:

ACCIDENT:

Place:
Time:
Day of Week:
Facts:
Weather &
Road Conditions:
Did Police attend?: yes no
Did Ambulance attend?: yes no
 
Plaintiff Vehicle:
License Plate No.:
Photos Taken?:
 
Defendant Vehicle:
License Plate No.:
Photos Taken?:

WITNESSES:

Name:
Address:                   
Name:
Address:

DEFENDANTS:

Name:
Address:                   
Name:
Address:

INSURANCE INFORMATION:

Insurance Company:   
Phone Number:  
Address:  
Coverage:  
Name of Adjuster:  
Claim Number:  
Statement given
to Insurer?:		  

MEDICAL INFORMATION:

Plaintiff's Injuries:       

Plaintiff's Doctors:

Name:
Address:                   
Name:
Address:
Name:
Address:

Hospitals:

Hospital Name:
Hospitalization Date:  
Hospital Name:
Hospitalization Date:

OTHER: (Chiropractors, Physiotherapists,
Massage Therapists)

Name:
Address:                   
Name:
Address:

Prior Injuries or Claims:

Medical History:
 
 
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ROBERTSON, DOWNE & MULLALLY
33695 SOUTH FRASER WAY
ABBOTSFORD, BC  V2S 2C1
 © 2007 Robertson, Downe & Mullally		 ABBOTSFORD: 604-853-0774
ALDERGROVE: 604-856-3627
CHILLIWACK: 604-793-7075
 		 MAPLE RIDGE: 604-463-4386
VANCOUVER: 604-856-3627
FAX: 604-852-3829
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