Fall down Personal Injury Fact Sheet

KENNETH A.VERCAMMEN ATTORNEY AT LAW 732-572-0500 FALL DOWN PERSONAL INJURY FACT SHEET Please fill out completely and return Todays date:    1. Plaintiff name:   address:   phone cell:   phone work:   phone home:   email   d/o/b:   Soc.. security:   Spouse   2a. Date of Accident:   town, county, state:   day of week   time:   weather:   Ground Coniditions:   where coming from & going to:   The dangerous conditions that caused the fall:   Fall down interview sheet rev 6/13/08 2. Description of Accident ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________     5. HOSPITALS-    ADDRESS,   DATE OF ADMISSION   DISCHARGE   6- X-RAYS,  TAKEN BY:    ADDRESS   DIAGNOSTIC TESTS: X-ray, MRI   DATE   RESULTS   7 DOCTOR-NAME   ADDRESS                           & nbsp;                PHONE   DATES OF TREATMENT:   DATE OF REPORTS:    7B. MEDICAL PROVIDER-NAME   ADDRESS                           & nbsp;                PHONE   DATES OF TREATMENT:   DATE OF REPORTS:   7C MEDICAL PROVIDER-NAME   ADDRESS                           & nbsp;                PHONE   DATES OF TREATMENT:   DATE OF REPORTS:   8. STILL BEING TREATED? MEDICAL PROVIDER-NAME   NATURE OF TREATMENT AND NATURE OF TREATMENT                           & nbsp;              9. AGGRAVATION OF PRIOR INJURIES BY ACCIDENT, PRIOR DOCTOR   10. Employer Name:   Address:   Job/Position   Gross/week   Net/week   Time Lost   Total Wages Lost:   11. IF RETURN TO WORK:    Current  Employer Name:   Address:   Job: Gross/week   Net/week   12- OTHER LOSS OF INCOME, EARNINGS   13. Medical bills, Doctor      Amount unpaid Paid       hospital bills,       medicine, etc.       Total medicals (As of ________):       14. OTHER OUT OF POCKET EXPENSES and OTHER LOSSES   Major medical card:   ____________ Hospital Bills:   ____________ Hospital  Records:   ____________ Medical Bills and Records    ____________ Photographs of Accident Site:   ____________ Photographs of Injuries, scars, cuts:   ____________ Repair damage estimate:   ____________                         16b Eye witness name:   address & phone:

20.  If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state:  (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication.

 22: Violation by Defendant of   law (i.e.  or other statute
   

24.  Have you every been indicted and convicted of a crime?   ______ (This question required by Rules of Court) 25. Plaintiffs private major- medical ex- Blue Cross   address:   phone:   Policy number   26 where Plaintiff was going to: ________________________________________ 27 Parts of body hitting ground:  _____________________ 28 Unconsciousness?  _____________________ 29  Skid marks by any car:   _____________________ Alcoholic beverages or medication within 12 hours before accident?  _______ Prior accidents involving injury in which you received an insurance settlement or suit was started? (Including workers compensation)? Prior car accidents with only property damage?   _____________________ Negligent actions by Defendant:     _____________________ What else did you tell police?  _____________________ Set forth the names of insurance agents and other individuals you discussed the case with and what did you say?  _____________________ Please prepare a Diagram of the accident site     _____________________ Are you receiving Medicare/ Medicaid? ___________ Are you receiving SSI? ___________ Is there anything else important?    ___________________________________________________  __________________________________________________  __________________________________________________ Documents to be supplied to attorney & in his possession: Police Report: Declaration Sheet: Medical/ Hospital Bills and Records: Photographs of Accident Site: Photographs of Injuries, scars, cuts: