Personal Injury Intake Questionnaire

1 Your Information

Full Legal Name

Date of Birth

Social Security Number (last 4)

Driver's License State

Driver's License Number

Current Mailing Address

Parish of Residence

Cell Phone

Email Address

Preferred Contact Method

Current Employer

Job Title / Occupation

Approximate Annual Gross Income

Hourly / Salary Rate

Is it safe for us to contact you at all of the above? If not, explain any restrictions:

2 Incident Information

Date of Incident

Time of Incident (approximate)

Street Address of Incident

City

Parish

State

Zip Code

Type of Incident (check all that apply)

Motor Vehicle Accident (auto, truck, motorcycle, commercial, rideshare) Premises Liability (slip/fall, trip/fall, negligent security, hazardous conditions) Products Liability (defective product, manufacturing defect, design defect, failure to warn) Dog Bite / Animal Attack Admiralty & Maritime (Jones Act, offshore injury, vessel negligence, maintenance & cure) Civil Assault, Battery & Civil Rights (intentional torts, excessive force, wrongful arrest) Toxic Tort & Environmental Exposure (chemical exposure, contamination, industrial exposure)

Brief Description of What Happened

Weather and Conditions at Time of Incident (if applicable)

3 Motor Vehicle Accident Details

Complete this section only if you were involved in a motor vehicle accident.

Your Vehicle

Year

Make

Model

Color

License Plate

Other Vehicle(s) Involved

Year

Make

Model

Color

License Plate

Your Direction of Travel

How Did the Collision Occur?

Your Estimated Speed (MPH)

Other Vehicle's Estimated Speed (MPH)

Traffic Controls and Lane Information

Your Role in the Accident

Driver Passenger Pedestrian Cyclist

Were You Wearing Your Seatbelt?

Yes No Not sure

Did Airbags Deploy?

Yes No Not sure

Was Your Vehicle Driveable After the Accident?

Yes No

Where Was Your Vehicle Towed? (if applicable)

Was a Police Report Filed?

Yes No

Police Report Number (if filed)

Police Department

Were Any Citations Issued? If So, To Whom?

4 Premises Liability Details

Complete this section only if your injury occurred on someone else's property due to unsafe conditions.

Property Address (Full Address)

Property Owner / Operator (if known)

Type of Property

Commercial (store, restaurant, office) Residential (apartment, rental, neighbor) Government (school, park, facility) Other

What Caused the Fall / Injury?

Was the Hazard Visible, Marked, or Warned About?

Yes, there was a warning No warning Unsure

How Long Had This Condition Existed? (if known)

Were There Any Witnesses? If So, List Names and Contact Info

Did You Take Photos or Video of the Scene?

Yes No

If Yes, Do You Have Them?

Was an Incident Report Filed with the Property Owner / Manager?

Yes No

Have You Heard of Any Prior Complaints About This Same Condition?

Yes No Unsure

If Yes, Describe:

5 Maritime & Offshore Details

Complete this section only if your injury occurred on a vessel or at an offshore/maritime work site.

Name of Vessel

Vessel Owner / Operator

Your Employer at Time of Injury

Were You a Jones Act Seaman at the Time of Injury?

Yes No Unsure

Location of Injury

U.S. Territorial Waters Outer Continental Shelf (OCS) Inland Waterways (non-navigable) Foreign Waters

Type of Work Being Performed

Maintenance & Cure Status

Being paid maintenance & cure Denied / Terminated Unknown

Describe Any Unseaworthiness Conditions (unsafe vessel conditions, poor equipment, inadequate manning, etc.)

5B Products Liability Details

Complete this section only if your injury involved a defective product.

Product Name / Description

Manufacturer

Retailer / Seller

Approximate Date of Purchase

Approximate Purchase Price

What Was Defective About the Product?

How Did the Product Cause Your Injury?

Do You Still Have the Product?

Yes — I still have it No — I discarded or returned it No — someone else has it

If You Still Have It, Where Is It Stored?

Were There Any Recalls or Warnings About This Product? (if known)

5C Dog Bite / Animal Attack Details

Complete this section only if your injury involved a dog bite or animal attack.

Type and Breed of Animal

Animal Owner's Name (if known)

Animal Owner's Address (if known)

Where Did the Attack Occur?

Was the Animal on a Leash or Confined at the Time?

On a leash In a fenced yard Running loose / not confined Unsure

Has This Animal Bitten or Attacked Anyone Before? (if known)

Yes No Unsure

If Yes, Describe Prior Incidents

Was Animal Control or Police Contacted?

Yes No

Was the Animal's Vaccination Status Confirmed?

Yes — up to date No / Unknown

5D Assault, Battery & Civil Rights Details

Complete this section only if your injury involved an assault, battery, excessive force, or civil rights violation.

Name of Perpetrator(s) (if known)

Was the Perpetrator a Law Enforcement Officer or Government Employee?

Yes No

If Law Enforcement, Which Agency?

Were Criminal Charges Filed Against the Perpetrator?

Yes No Unsure

If Yes, Case Number and Court (if known)

Describe What Happened

Is There Video, Body Camera, or Surveillance Footage?

Yes No Unsure

5E Toxic Tort & Environmental Exposure Details

Complete this section only if your injury involved chemical exposure, contamination, or environmental hazards.

Substance / Chemical Involved (if known)

Source of Exposure

Workplace Consumer product Environmental (water, air, soil) Other

Employer at Time of Exposure (if workplace)

Approximate Start of Exposure

Approximate End of Exposure

When Did You First Notice Symptoms?

Was Safety Equipment Provided?

Yes No Some, but inadequate

Describe the Exposure and Your Symptoms

6 Injuries & Medical Treatment

Describe All Injuries Sustained

Did You Go to the Emergency Room?

Yes No

Hospital / Facility Name

Date of ER Visit

Were You Transported by Ambulance? (even if not taken to an ER)

Yes No

All Treating Physicians and Facilities (name, specialty, type of treatment, dates)

Current Treatment Status

Ongoing treatment Completed Pending additional treatment

Do You Have Any Prior Injuries to the Same Body Parts?

Pre-Existing Medical Conditions

Current Medications

7 Insurance Information

Your Auto Insurance (if MVA)

Insurance Carrier

Policy Number

Your Health Insurance

Carrier

Policy Number

Other Party's Insurance (if known)

Carrier

Policy Number / Claim Number

Do You Have Uninsured / Underinsured Motorist (UM/UIM) Coverage?

Yes No Unknown

UM/UIM Policy Limits (if known — check your declarations page)

Do You Have Stacking? (if known)

Do You Have Medical Payments (MedPay) Coverage on Your Auto Policy?

Yes No Unknown

MedPay Limits (if known)

Workers' Compensation (if work-related)

Employer's Workers' Comp Carrier

Policy / Claim Number

Any Other Applicable Insurance or Coverage

8 Lost Wages & Economic Impact

Employer Name

Job Title

Hourly or Salary?

Rate (hourly rate or monthly salary)

Date You Stopped Working

Have You Returned to Work?

Yes No Partial / Modified duty

If Returned, Date of Return

Total Lost Wages to Date (estimate)

Reduced Earning Capacity / Ongoing Loss

Any Other Economic Losses

9 Witnesses & Evidence

Witnesses to the Incident (Up to 3)

Witness 1

Name

Phone

Email

Witness 2

Name

Phone

Email

Witness 3

Name

Phone

Email

Did You Take Photos or Video of the Scene or Your Injuries?

Yes No

If Yes, Describe What You Captured

Is Dashcam, Surveillance, or Security Footage Available?

Yes No Unsure

If Yes, Describe Source and Location

Have You Given Any Statements? (To police, insurance, other parties, etc.)

Have You Posted About This Incident on Social Media?

Yes No

If Yes, Where and When?

10 Other Parties & Prior Legal History

Names of All Potentially Responsible Parties

Have You Had Any Communication with the Other Party's Insurance?

Yes No

If Yes, Describe Communications and Any Offers

Have You Given a Recorded Statement to Any Party?

Yes No

If Yes, To Whom and When?

Have You Signed Any Documents or Releases?

Yes No

If Yes, Describe What You Signed

Prior Personal Injury Claims or Lawsuits (Last 10 Years)

Prior Criminal History

11 Governmental Entity Involvement

Was a Governmental Entity Involved in Your Injury?

Yes No

If Yes, Which Entity?

State agency Parish / County agency Municipal (city/town) Federal agency

Nature of Governmental Entity's Involvement

Have You Sent Written Notice to the Governmental Entity?

Yes No Unsure

IMPORTANT: Many Louisiana cities, parishes, and other government bodies require you to give written notice of your claim BEFORE filing suit — often within about six months of the incident — and missing that deadline can bar your claim against the government. These requirements vary by entity. Contact us IMMEDIATELY if a government entity may be involved so we can identify and meet any applicable notice deadline.

12 Conflicts Check

List All Party Names (You, Defendants, Insurance Companies, Witnesses, Anyone Else Involved)

Have You Ever Been a Client of Aertker Legal, LLC?

Yes No

If Yes, Describe the Prior Matter

Do You Have Any Known Connection to Aertker Legal, LLC or Its Attorneys?

13 Your Goals & Additional Information

What Is Your Most Important Outcome for This Matter?

Is There Anything Else Important That We Should Know?

How Did You Hear About Aertker Legal, LLC?

Google / Online search Facebook Personal referral Other

If Referred by Someone, Please Provide Their Name

14 Acknowledgment

I certify that the information provided in this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that this questionnaire does not create an attorney-client relationship, and that no legal advice has been provided. I have read and understand the confidentiality notice above. I authorize Aertker Legal, LLC to contact me regarding my inquiry and to gather additional information as necessary to evaluate my claim. I understand that I should not delete, alter, or post about this incident on social media, and that I should preserve all evidence related to this matter — including photographs, videos, text messages, the product involved (if applicable), and any physical evidence — in its current condition.

Printed Name

Signature

Or type your name to sign:

Date

Personal Injury Intake Questionnaire

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