Law Office of Robert Mansour - Personal Injury Questionnaire
The following secure form is very important. The information you provide helps us provide you with the best advice. All information you provide remains confidential. Be as accurate and complete as you can. If you don't wish to fill out this form, just bring this information to our first meeting.
When is your initial consultation with our office?
Your Full Name:
First Name
Middle Name
Last Name
What is your home address?
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
E-mail Address:
How did you learn of our office?
Date and Time Accident Occured:
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Please provide a very detailed description of the accident - include location, number of cars involved, how the accident happened, etc.
How would you describe the severity of the accident?
Please Select
Very Light
Moderate to Light
Moderate
Moderate to Heavy
Heavy
Very Heavy
Was anyone else in the accident with you? If so, who?
On a scale of 1 to 10, how would you describe the extent of property damage to your vehicle? A "1" would be very minor with hardly any visible damage and a "10" would be tremendous damage (people would wonder how someone survived!)
Any other information about the property damage you wish to add?
Have any photos been taken? If so, where are they and who has them?
Please upload all photos from the accident. (i.e., Scene of accident, damages to vehicle, and bodily injuries.) - If you have not taken photos of the damage to your car or your injuries, you should do so asap. Photos you take should be designed to illustrate the severity of the impact from several angles and distances!
Upload a File
Cancel
of
Was there a Police Report taken? If so, what agency? (Please list police department, officer's name and report number below)
Please provide a VERY detailed list of any injuries you sustained in the accident. Be as complete as you possibly can be. For example, "my back hurt" would be a simple description versus "My back has sharp pain, radiating into my shoulder blades. I feel more pain in the mid back but I also have pain in my lower back. It feels like a dull aching sensation." The more descriptive the better.
When was medical help first received for injuries? (i.e., Ambulance, Hospital, ER, Doctor, if any). Please provide details (name, address, phone number, etc.)
Did you have any bruising on your body from the accident? If so, where?
Radiating pain anywhere on your body?
Did you head or body strike anything inside the car? If so, what?
Did you Airbag(s) Deploy?
Please Select
Yes
No
Did you seats break?
Please Select
Yes
No
Please provide us with the following: (Your car insurance company info - including name of company, adjustor, claim number, policy number, etc.)
Responsible Driver (Party at fault):
First Name
Middle Name
Last Name
Responsible Driver Info:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Responsible Driver's Main Contact Number:
-
Area Code
Phone Number
Responsible Driver's License:
Please provide us with the following: (Responsible party's insurance information including company name, adjustor, claim number, policy number, etc.)
Any other information you wish to add that might be helpful?
Submit Information (Please print first if you wish)
Print Form
Should be Empty: