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PERSONAL INJURY QUESTIONNAIRE

Directions: Please try to answer as many questions as possible so that the lawyers at Weselis & Suchoparek, LLC can adequately assess all your options. All information disclosed is entirely confidential and covered under the attorney / client privilege. Please return this form after it is completed by clicking the submit button below. Our attorneys will then be in contact with you to discuss your options with a free case consultation.


Background Information

Marital Status

Employment

Are you employed?
Did you change jobs or job duties because of your accident?

Incident Information

Were you at fault for the incident? *
Was there a police report taken?
Was an ambulance called to the scene?
Were there any witnesses?
Did you make any statements to anyone concerning this incident?
Do you have any injuries from this incident?
Do you have health insurance? *
Are you currently going to see a doctor or specialist?

Additional Personal Background Information

Have you ever made a claim or brought a lawsuit against an insurance company?
Have you spoke to an insurance adjuster to date regarding this incident?
Find Out More

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