Petrillo & Goldberg Law
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Scott M. Goldberg
Steven Petrillo
Scott D. Schulman
Jeff Thiel
Steven Petrillo Jr.
Brittany Petrillo Fisher
Robert Goldberg
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ESPAÑOL
Motor Vehicle Accident Client Intake
General Information
Name
*
First
Last
Date of Birth
*
Month
Day
Year
Current Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Prior Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Telephone Number
*
Home
Work
Cell
Email
*
Emergency Contact Numbers (in case of emergency and you cannot be reached)
*
Number
Name and Relationship to You
Marital Status
Marital Status
Spouse's Name
Spouse's Age
Children and Their Automobile Insurance Information
Children (Natural & Adopted)
Their Automobile Insurance Information (If Applicable)
Names of Any Other People Residing in Household and Their Relationship to You
Names of Any Other People Residing in Household
Relationship
Their Automobile Insurance Information (If Applicable)
Educational Background
Person or Means of Referral to our Firm
*
Incident Data
Date of Accident
*
Month
Day
Year
Time of Accident
*
:
Hours
Minutes
AM
PM
AM/PM
Location of Accident
*
Driver of Your Vehicle (Relationship to You)
*
Owner of Your Vehicle
*
Year, Make and Model of Your Vehicle
*
Year
Make
Model
Registration (VIN) No. of Your Vehicle
*
Tag No. of Your Vehicle
*
Names, Address and Phone Number of All Occupants of Your Vehicle
Name
Address
Phone Number
Name, Address and Phone Number of the Driver of the Other Vehicle Involved in the Accident
Name
Address
Phone Number
Names, Address and Phone Number of the Driver of the Any Other Vehicle Involved in the Accident
Name
Address
Phone Number
Name and Address and Phone Number of All Named Witnesses
Name
Address
Police Department at Scene of Accident
*
If Summons Issued, to Whom, Charge and Outcome
Name
Charge
Outcome
Describe All Statements Given at the Scene of Accident to the Police
*
Describe All Statements Given at the Scene of Accident to the Other Driver
*
Describe All Statements Given at the Scene of Accident to Any Other Witnesses or Person(s) at the Scene of the Accident
*
Was Your Vehicle Damaged?
*
Yes
No
Have Any Photos Been Taken of the Damage or Scene of the Accident?
*
Yes
No
If Yes, in Whose Possession Are There Photographs?
Have Damage/Repair Estimates of Vehicle Been Taken? If Yes, by Whom?
*
Prior Claim History
If You Have A Prior Lawsuit or Claim, Please State the Following
Date of Prior Accident (If More Than One, Click the Plus Button to Add More)
Nature of Accident (MVA, S&F, Work-Related, Sports-Related, Etc.)
Injuries Sustained in the Accident
Were There Any Surgeries as a Result of Above?
Yes
No
If Yes, Please Describe
Name & Address of Your Prior Attorney
Name
Address
Phone Number If Available
The Outcome of the Litigation
Settled
Litigated
Pending
Location of All The Documentation For This Prior Lawsuit or Claim
Please State the Name of Any Other Medical Conditions Whether Related to Trauma or Otherwise Which You Have Suffered in the Past
Employment Information
Name of Employer
*
First
Last
Address of Employer
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's Phone Number
*
Title/Position Held
*
Please Describe Your Job Duties
Length of Employment
*
Have You Lost Any Time From Work As A Result of This Accident?
*
Yes
No
If Yes, How Long?
Have You Filed For or Are You Eligible For Temporary State Disability Benefits?
*
Yes
No
Gross Weekly Pay? (Also Please State Whether You're Hourly or Salary)
What is the Name and Phone Number of Your Supervisor?
*
Name
Phone Number
Insurance Information
Name of Your Auto Insurance Company
*
Address of Your Auto Insurance Company
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Auto Insurance Policy No.
*
Claim Number (If Applicable)
Name, Address and Phone Number of Adjuster Assigned (If Applicable)
Name
Address
Phone Number
Name and Address of Other Party's Auto Insurance Company (If Known)
Name
Address
Name and Address of Your Private Health Insurance Carrier
*
Name
Address
Provide the Insurance Policy Number of Your Private Health Insurance Carrier
Is Your Healthcare Through the New Jersey Family Care Program?
*
Yes
No
Injury Information
Did An Ambulance Come to the Scene of the Accident?
*
Yes
No
If the Answer to the Above Question is Yes, Which Hospital Were You Transported To?
Hospital Name
Location
Date of Service
Date of Discharge
Have You Ever Had Any Other ER Treatment in the Hospital?
*
Yes
No
If Yes, Which Hospital and a Brief Description of Reason for Treatment
Hospital Name
Reason for Treatment
Name and Address of Family Physician
Name
Address
Name of Physician Treating You For Your Injuries From This Accident
First
Last
Name and Address of Any Specialists Involved With Your Treatment For This Accident
Name
Address
Were Any Diagnostic Test Performed?
*
Yes
No
If Yes, What Type of Test, Date Performed and Results (If Any)
Type of Test
Date Performed
Results (If Any)
Please Describe All of Your Injuries That You Believe Are Related to this Accident
*
Please State the Nature of the Treatment You Are Currently Undergoing
*
Please Describe the Accident the Best You Can
*
Name
This field is for validation purposes and should be left unchanged.
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