Wrongful Death

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Personal Information

Name
Email Address
Address
City
State
Zip
County
Home Phone
Work Phone
Date of Birth
Social Security Number
Number of Children
How did you hear of Merkle Law Firm?

The Accident

Explain how the accident occurred
If this was an auto accident was the deceased driving or passenger?
Was there a police report?
 Yes
 No
Did you get a copy?
 Yes
 No
Was there a traffic ticket issued?
 Yes
 No
To whom?
For what?
Did the defendent say anything admitting fault?
 Yes
 No
If yes, what did he/she say?
Did the defendant's insurance company pay any property damage?
 Yes
 No
Amount they paid
If not, who paid?
What are the names of the witness(es) to the accident:
If the death did Not occur in an automobile accident, please explain how it occurred.
Do you have any pictures that may help with this case?
What are the names of the witness(es) to the accident?

Please provide before and after pictures of the damaged vehicle.

The Decedent's Inuries

Did the deceased go to the emergency room?
 Yes
 No
If Yes, where?
Did he/she go in an ambulance?
 Yes
 No
What were the injuries from this accident?
Please list the doctors and all medical providers the deceased saw for injuries from this accident
What is the total amount of medical bills?
Have any of them been paid yet?
 Yes
 No
By who / what insurance company?
What Funeral Home was used for the decendent's burial?
Are there any expenses owed for the funeral?
 Yes
 No
Amount

Estate

Has there been an Estate opened for the decendent?
 Yes
 No
If Yes, who is the attorney?

Work Losses

Employer's name
What was the deceased's hourly pay rate?
What were his/her work duties?

Insurance Information

Your Auto Insurance

Company Name
Adjuster
Address
Phone Number
Insurance Claim Number

Your Health Insurance

Company Name
Adjuster
Address
Phone Number
Insurance policy number
Insurance claim number

Defendant's Insurance

Company Name
Adjuster
Address
Phone Number
Insurance policy number
Insurance claim number

Other Insurance Losses

Please provide any other insurance the decedent had such as, life ins. policies, mortgage, other loan or credit card death benefit policies or the like.