Personal Injury Questionnaire


First Name *
Last Name *
Street Address
City
Province
Postal Code
Home Phone
Work Phone
Fax
Email Address *
Date of Birth
Date of Injury *
Where did the injury occur?
How was the inury caused?
What is the extent of your injuries?
Have you had any employment losses due to the accident?
What is your occupation?
What is your annual salary or weekly income?
What ongoing problems are you experiencing?
Who is your insurance company?
What benefits, if any, have you received to date?
Please provide a list of hospitals, doctors and/or specialists you have seen as a result of your accident.
Is there anything else we need to know in order to decide if we can help?