SLIP & FALL INTAKE FORM Name * First Name Last Name Middle Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone # * (###) ### #### Email * Date of Birth * MM DD YYYY Social Security Number (SSN) * Secondary Contact Person's Name * First Name Last Name Secondary Contact Person's Relation * Secondary Contact Person's Phone # * (###) ### #### Where did this incident occur? * Please provide the exact location. Date of Incident MM DD YYYY Time of Incident (approximate) Hour Minute Second AM PM Describe in your own words what happened. * Were there any warning signs or other indications of a dangerous situation? Yes No Not that I saw or am aware of. Was there a Police Response or Incident Report taken? There was a Police Response There was an Incident Report taken No Police Report or Incident Report Unsure Witnesses Please name and provide contact information for any witnesses. Employees / Management spoken to. If you spoke with any employees or management, provide their names or a description of them here. Do you have photos or video of the incident or establishment's property. * Describe your Injuries * Do you have Health Insurance? * Yes No Unsure Health Insurance Provider's Name and Policy Number * Were you transported to a hospital via EMS or Ambulance? * Yes No Treatment since the Incident * Name the facility where treatment was rendered and it's address. Referral * Thank you! We will be in touch soon to further discuss your case. Please note, that submitting an Intake Form does not create an attorney client relationship.
