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.

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Background Information

First Name *

Last Name *

Current Home Address

City

State/Province

ZIP / Postal Code

Email Address *

Phone *

Date of Birth

MonthSelect month123456789101112

DaySelect day12345678910111213141516171819202122232425262728293031

YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926

Marital StatusMarriedSingleDivorcedSeparatedWidowed/Widower

Employment

Are you employed?YesNo

Employer Name

How Many Years Employed?

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

Please describe.

Please do not fill in this field.