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Personal Injury Intake Form

Request a Free Personal Injury Consultation

Please complete this Personal Injury Intake form. Our website is secure and the date is encrypted to ensure safe transmission of your personal information.

If you have any questions or concerns, please contact our office.

"*" indicates required fields

Name*

Address*

City*

State*

Zip Code*

Email Address*

Home Telephone*

Cell Phone

Work Phone

Height*

Weight*

Right or Left Handed*

Social Security Number*

Date of Birth*

Referred by:

If you had prior Counsel, please state who:

Date, time, and place of collision occurred:*

Parties Involved*

Who Investigated?*

Montana Highway Patrol

City Police

Other

Copy of Crash Report?*

Crash Number*

Who was at Fault?

Citations Issued?

If YES, What Violation(s)?

Description of How the Collision Occurred:*

Transported by Ambulance?*

Date of First Treatment

Symptoms Immediately after Wreck?

Symptoms now:

Diagnosis?

What Medical Providers were seen after Wreck?

Diagnostic Tests?

X-Rays

CT Scans

MRI

Other

Results of Diagnostic Tests

Your Vehicle Info in Accident (Make and Model)*

Vehicle Towed from Scene?*

If Yes, Who Towed it?

Cost of Repairs*

Untitled

Towed from the Scene?

If Yes, Who Towed it?

Cost of Repairs*

Your Insurance (Name of Adjuster, Telephone Number, Claim Number and Policy Number:

Did Your Insurance Take a Statement?

Please state Medical Payment Coverage and Underinsured Motorist Coverage, if applicable?

How Many Vehicles on Policy?

At-Fault Insurance (Name of Adjuster, Telephone Number, Claim Number and Policy Number):

Did At-Fault Insurance Take a Statement?

Policy Owner's Name

Photos

Yes, of vehicles

Yes, of injuries

Yes, of scene of wreck

If there were witnesses, please state the names of the witnesses:

Your Place of Employment

Your Position/Description of Duties:

Lost Time because of Injuries?

Prior wrecks

When and what where the injuries?

Are you a Medical Marijuana user?

Please state your Education, including when and where (High School, College and Vocational)

Your Health Insurance (Company Name, Contact Info, Member ID and Group Number:

Any other Insurance Available?

Medicade

Medicare

Homeowners

Health Insurance

VA

Accidental Coverage

Gap Insurance

Name of Insurance Companies

Other Relevant Information

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Phone

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Practice Areas

Bicycle Accident
Car Accident
Nursing Home Neglect
Spinal Cord Injury
Traumatic Brain Injury
Truck Accident
Wrongful Death

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First Name*

Last Name*

Phone*

Email*

Describe Your Case*

Name

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Our Office

1382 Airport Road,
Kalispell, MT 59901

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Email

info@kortumlawoffice.com

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