Whittemore Law

Client Intake

Kindly fill out the client intake form with thorough details. Expect to hear from us within 1-2 business days.

Personal Information

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Address

Spouse's Name

First Name

Last Name

Spouse's Phone

(###)

###

####

Date of Accident

YYYY

(1) Year/Make/Model of your Car Involved in Accident

(2) Year/Make/Model of the Other Car Involved in Incident

(3) Year/Make/Model of the Other Car Involved in Incident

(1) Your Driver's License Number

(2) Other Driver's License Number

(3) Other Driver's License Number

Where did the accident occur? Please provide exact location (street names, city, identifying landmarks)

When did the accident occur?

Where were you coming from and going to?

Please explain what happened? Be provide as much detail as possible.

Name and phone numbers of everyone that was involved in the accident (including passengers and pedestrians)

Name and phone numbers of all known witnesses

If there were minor children involved, please provide their full name and date of birth.

Who is your auto insurance carrier?

What is your insurance policy number?

Do you have a Claim Number for the accident? If so, please provide it.

Who is the auto insurance carrier for the other driver?

Is there a Claim Number for the other driver's insurance carrier? If so, please provide it.

Is there a police report/incident report? If so, what is the report number?

Do you have health insurance? If so, who is your carrier and policy number?

Name and phone number of all medical providers.

Did you go to the hospital? If so, please provide the name and address of the hospital.

Describe your injuries.

Any previous similar injuries? Explain.

Are there any pictures of the accident or injuries? If yes, please email contact@whittemorefirm.com with pictures.

Whittemore Law

Client Intake

Personal Information

Accident Details

Auto Insurance

Health-Related

Anything Else?

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