updated 1/29/98 2:23 PM PST    

             PERSONAL INJURY WORKSHEET

DATE OF INTERVIEW: __________
DAY AND DATE OF ACCIDENT:________________
CLIENT'S NAME:_____________________
____ Driver _____ Passenger _____Other:
Address:_________________________
Phone Numbers: Work:______ Home:______
Social Security_______________
Birthdate: ______________

EMPLOYMENT:
Employer: ______________________
Self-employed business name: __________________
Address: ___________________________________
Position and Duties: _________________________
________________________________________________

Compensation:$_________  Date of Confirmation ____

Additional jobs: ___ yes ___ no
Employer: ____________________
Address: ____________________

Position and Duties:____________________________
_________________________________________________

Compensation: $_______ Date of Confirmation_________


CLIENT'S VEHICLE INFORMATION:
Vehicle Make: ________________ Year _______
License Plate: _____________ ID No. _______________
Is Client Registered Owner: ____Yes ___ No
Name of Registered Owner: _____________________
Address of Registered Owner: ____________________
__________________________________
Blue Book Value at time of accident: $____________

CLIENT'S INSURANCE INFORMATION:
Client's Auto Insurance:
Name of carrier: ___________________
Address: ___________________________
Phone Number:_____________
Policy No.: _________________
Type of Coverage:__________________


Agent's Name: ___________________

Agent's Address: _____________________
Agent's Phone Number:___________________
Adjuster's Name:________________________
Adjuster's Phone Number:_____________________

Medical Insurance Carrier ______________________

(a) Name: _____________________________
(b) Address: ___________________________
(c) Phone: __________________________
(d) Contact Person:______________________
(e) Policy No ________________
(f) Claim No. ___________________


Other Medical Insurance Available: ___Yes ___No
(a) Name:
(b) Address:
(c) Phone:
(d) Contact Person:
(e) Policy No.:
(f) Claim No.

DEFENDANT'S INFORMATION:

Defendant 1: ___Driver ___Passenger ___Other
Address:
Phone Number:
Employer Address:
Employer Phone Number

Vehicle Make:
License Plate:

Auto Insurance Carrier:
Carrier' Address:
Carrier's Phone Number:
Policy No.:
Claim No.

Contact Person:

Is defendant 1 the registered owner? ___Yes ____No
Registered owner's name:
Registered Owner's address:
Registered Owner's insurance:

Defendent 2: ___ Driver ___Passenger ___Other
Address:
Phone Number:
Employer Address:
Employer Phone Number:
Vehicle Make Year
License Plate ID No.
Auto Insurance Carrier:
Carrier's'Address:
Carriers's Phone Number:
Policy Number: Claim No.:
Contact Person:

Is defendant 2 the registered owner? ___Yes ___No
Registered owner's name:
Registered owner's address:
Registered owner's insurance:


Other Provider:

Address:
Phone Number:
Date of first visit
Doctor's Name: