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James E.Smith, ESQ.
Names of person, address, phone and e-mail of person injured, his spouse, if any, and his parent or guardian if a minor.
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Description
Names
Description
Address
Description
Phone
Description
e-mail of person injured
Description
Spouse
Description
Parent or guardian if a minor.
Description
Date and place of accident or injury?
Date
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Place
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What happened and why or how?
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Have you gone for medical treatment?
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Yes
No
What are your injuries?
Details
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When did you first go in for medical treatment and where?
Details
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How much are your medical bills?
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What is your diagnosis and prognosis?
Diagnosis
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Prognosis
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Have you finished your medical treatment?
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Yes
No
Do you have medical insurance which has paid on your bills for this accient?
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Yes
No
Have you lost wages or income as a result of this accident?
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Yes
No
Was there an incident report of the accident or event?
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Yes
No
Did you give a recorded statement to a claims adjuster, investigator, police or security?
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Yes
No
Do you need a referral to a doctor, chiropractor or physical therapist?
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Yes
No
Do you need a referral to a rental car company or personal injury lender?
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Yes
No
Who is the insurance company for the other side?
Name of company
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Do you have liability, uninsured motorist or medical payments insurance yourself?
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Yes
No
Did the police, highway patrol or other government agency investigate this?
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Yes
No
Did this happen while working, and, if so, do you have a worker's compensation claim?
Enter details
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Do you have any prior accidents wherein you injured yourself in the same body part(s)?
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Yes
No
What compensation do your believe that your're entitled to?
Enter details
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If you are out of town are you willing to come to Las Vegas for the arbitration or trial?
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Yes
No
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JAMES E. SMITH, ESQ. � 2008