Law Office of Mark Muffoletto, LLC

3201 Rogers Avenue, Ste 301
Ellicott City, MD 21043

(410) 465-4665

CLIENT & CASE INFORMATION

This form is designed to give us an advanced look at the information to be discussed during your consult. If you do not know the answer to a question, leave the information blank and we will discuss it when you meet with our staff. Some of what is asked may not exist until later in your case or will need to be recovered through other means. Thank you for taking the time to complete the form and we look forward to speaking with you.

A. Personal Information

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Social Security #:

Date of Birth:

Driver’s License Number:

Marital Status

Married

Separated

Divorced

Single

Engaged

Is the client a Minor?

Parents' or Guardians' Names

Health Insurance Information

Do you have Private Health Insurance?

Yes

Are you Employed

Yes

Are you currently receiving Medicare?

Yes

Are you currently receiving Medicaid?

Yes

Are you currently receiving Social Security Disability?

Yes

Are you in the process of applying for SSDI?

Yes

B. Accident Information

Date of Accident:

Time of Accident:

Location of Accident:

Street/City/County/State

Briefly describe how the accident took place:

Did the police respond to the scene of the accident?

Yes

Was an accident report ever written?

Yes

What were the weather conditions:

Passenger(s) in your vehicle:

Passenger 1:

Yes

Passenger 2:

Yes

Witness to this accident:

Witnesses Names, and Contact Information?

Other Information:

C. Injuries Sustained and Medical Information

Describe in detail the injuries you sustained as a result of this accident:

Were you taken by Ambulance?

Yes

Medical Providers Seen

Please provide all medical providers you have visited so far from the date of accident being sure to indicate dates of treatment.

X-rays Taken?

Yes

Medical Provider 1:

Yes

Medical Provider 2:

Yes

Medical Provider 3:

Yes

Lost Wage Information

Have you lost wages and/or time from work as a result of this accident?

Yes

Prior Medical Injury and Accident History

List all medical problems/injuries/accidents you experienced in the past ten (10) years.

Prior injury, illness or accident 1:

Yes

Prior injury, illness or accident 2:

Yes

In this accident, were you the:

Driver

Passenger

Owner Information (if other than you):

Name of owner of vehicle:

Address of owner of vehicle:

Your Auto Insurance Information

Do you own the Car

Yes

Insurance Company:

Name of Insured:

Year/Make/Model:

Color:

Tag No.:

State that Policy was written (Please check one):

Other

Policy Number:

Claim Number:

Adjuster:

Phone Number for insurance adjuster/company:

Description of damage to vehicle:

Did your airbags deploy?

Yes

Was your vehicle towed from the scene?

Yes

Has the damage to your vehicle been appraised?

Yes

Has your vehicle been repaired?

Yes

Personal property lost or damaged in the accident:

Other Information:

E. At Fault Party/Vehicle Insurance Information

Driver’s Name:

Address:

Phone Number:

Male or Female:

Driver’s License No.:

Approximate Age:

Owner’s Name:

Address:

Year/Make/Model:

Color:

Tag No.:

Insurance Company:

Name of Insured:

Policy Number:

Claim Number:

Adjuster:

Phone Number:

Description of damage to their vehicle:

Did their airbags deploy? (Leave Blank if unsure)

Yes

Any injuries to other driver or Passenger? (leave Blank if you are unsure)

Yes

Passenger(s) in the other vehicle:

Passenger 1:

Yes

Passenger 2:

Yes

If anyone at the scene of this accident spoke to you, please provide the name of the person (s) and a content of the conversation:

Other Information that you want us to know:

Specific Questions from you:

If there are specific questions that you have, feel free to list them here and we will make sure that we address them during the consult.

DOCUMENTS: Please upload all files related to your case so we can review for your consult. NOTE: If we do not have the related documents PRIOR to your consult, you will have to reschedule.

NOTE:

If you are unable to use a full sized scanner, for the best results, please use a PDF scanner app as such as JotNot or PDFelement.

THIS IS NOT AN AGREEMENT OF REPRESENTATION

Please understand that this form does not create a binding agreement or an attorney/client relationship and one will not exist until a retainer agreement is executed. I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

I understand that this form does not create a binding agreement or an attorney/client relationship and one will not exist until a retainer agreement is executed. I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU

Thank you for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We look forward to discussing the case further with you.

Please click the SUBMIT button below when you have finished answering all questions.