Merkle Law Firm, Harrisburg, South Dakota

Automobile Collision Wrongful Death Slip & Fall Injury

Other Injury Claims

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Other Injury Claims

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Personal Information

Name

Email Address

Address

City

State

Zip

Couuty

Home Phone

Work Phone

Date of Birth

Social Security Number

Number of Children

How did you hear of Merkle Law Firm?

Your Injuries

Did you go to the emergency room?

Yes
No

If yes, where?

Did you go in an ambulance?

Yes
No

What are your injuries?

Please list all doctors/ medical providers that you have seen for your injuries

What is the total amount of your medical bills to date?

Have any of them been paid yet?

Yes
No

By who/ what insurance company?

Work Losses

Have you lost any time from work?

Yes
No

Hours/days lost from work?

Employer's name

What is your hourly pay rate?

Has your doctor given you any work restrictions?

Yes
No

If Yes, what are they?

Other Injuries

Have you had any other similar injuries?

Yes
No

If yes, please describe:

Have you ever had any other insurance claims?

Yes
No

If yes, please describe:

Have you had any other accidents?

Yes
No

If yes, please describe:

Your Injuries

Have any of your activities been interrupted due to this accident?

Yes
No

If Yes, please describe. Note each activity and if you can't do or can do with pain:

Witnesses to activity/lifestyle changes

If you have any pictures showing the injured person in action before the injury please provide them.

Additional Comments

Comments

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