Contact

Call or Visit

T: (323) 426-3143
F: (818) 990-6140

Monday – Friday: 8:30AM – 5PM
Saturday – Sunday: By Appointment

Email

General Inquiries
bgoldsmith@goldsmithcalaw.com

Personal Injury Evaluation Form

Name

First Name

Last Name

Address

Email Address

Phone Number

(please provide phone number and/or email address)

Driver's License Number

Social Security Number

Date of Birth and Age

Spouse's Name

Children

Date of Accident

Time Accident Occurred

Driver of your Car (if automobile accident)

Registered Owner of Car

Year/Make/Model (of Car)

License Number

Color of Car

Amount of Property Damage

Location of Vehicle

Passenger Information in Car

Driver of Defendant's Car Information (Name)

Defendant Driver's Address

Registered Owner of Defendant's Car

Defendant's Insurance Information

Any other additional information relating to the injury?

Adjuster Contact Information (if applicable)

Witnesses (name, address and phone number)

Prior Injuries

Any Prior Accidents You Were Involved In?

Your Auto Insurance Information

Med Pay insurance Information. What is your limit?

Do you have uninsured motorist? What is your limit?

Health Insurance Information

Employer (name and address)

Your Occupation

Estimated Loss of Earnings

Descibe Your Injuries

Did any part of your body strike the interior of the vehicle?

Do you have bruises and cuts from the accident?

List your Physicians

Hopsitals you have been treated atWere

Were you transported by Ambulance

Location of Accident

How did the accident happen?

Were you wearing a seat belt? If yes, what type of sealt belt?

What time did the accident happen?

Weather condition during accident

Road conditions during accident

Day of the week

Traffic conditions

Was there lightning?

Who investigated the accident?

What is the Police Rport Number?Was a

Was a Ticket issued? If so, to whom?

Were any drugs or alocohol involved?

What was your direction of travel?

What was Defendant's Direction of Travel?

Were you driving on a street or highway?

Nearest Intersection?

Cross Streets