THE LAW OFFICES OF HARLAN B. KISTLER

Intake Form


Todays Date	mm/dd/yyyy
* Name
* Age
Phone Number - Home
Phone Number - Cell
* Email
* Type of Accident/Incident
* Date of Accident/Incident	mm/dd/yyyy
* Location of the accident
* Was a police report filed?
* If a police report was filed, who filed it?
* Were property damage photos taken?
* Do you have a property damage estimate?
* What is the propert damage estimated amount?
* What were the injuries sustained?
What medical facilities have evaluated/treated you in regards to this incident?

Medical facility visit - 1
Medical facility visit - 2
Medical facility visit - 3
Medical facility visit - 4
Medical facility visit - 5
Medical facility visit - 6
Insurance Information

- Health Insurance -
Carrier
Medi-Cal/Medi-Care
- Prospective Clients Insurance Info -
Carrier
Address
Claim Adjuster
Claim No
Claim Adjuster’s No
- Insurance Info. of Other Party -
Name of other driver
Carrier
Address
Claim Adjuster
Claim No
Claim Adjuster’s No
* Please describe accident/incident
How did they hear about our firm
* denotes required field

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