|
Abacus Law Client In-Take Sheet Sample Law Area: Personal Injury AC Consulting Legal Office Technology & Automation |
LAW OFFICE INFORMATION SHEET
Current Date: ____________________Statute Date: ______________
1. NEW MATTER INFORMATION - Add information to MATTERS SCREEN 1
Matter Name: __________________________________________________
File/Case No.:_________________________________________________
Atty.: ________________________________________________________
Case Code: ____________________________________________________
Court: ________________________________________________________
Case Open Date: _______________________________________________
2. MATTER INCIDENT INFORMATION - Add information to MATTERS SCREEN 6
Referred By: __________________________________________________
Language: _____________________________________________________
Interviewer: __________________________________________________
D/A: __________________________________________________________
Day: __________________________________________________________
Time: _________________________________________________________
P/R (y/n): ____________________________________________________
P/R Date: _____________________________________________________
3. PLAINTIFF'S GENERAL INFORMATION - Add information to NAMES SCREEN 1
Class:_________________________ (plaintiff driver or passenger)
Gender (m/f): ________________
Marital Status (s/m/d/w): ______
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Home Phone: (_____)____________________________________________
Work Phone: (_____)____________________________________________
Fax: (_____)___________________________________________________
Pager/Cell: (_____)____________________________________________
4. PLAINTIFF'S PERSONAL INFORMATION - Add information to NAMES SCREEN 6
D.O.B: _____________________________ Age: _____________________
SS#: __________-__________-__________ CDL#: ___________________
Current Employer : ____________________________________________
Occupation: ________________________________ Rate: ____________
Currently Working (y/n): ______ Medi-Cal #: ___________________
Health/Medical Insurance: _____________________________________
Insurance/Policy #: ___________________________________________
Group #: ______________________________________________________
5. PLAINTIFF'S AUTO INSURANCE INFORMATION - Add information to NAMES SCREEN 7
Company: ______________________________________________________
Coverage: _____________________________________________________
Address: ______________________________________________________
Phone: (_____) ________________________________________________
Agent: ________________________________________________________
Phone: (_____)_________________________________________________
Policy #: _____________________________________________________
Claim #: ______________________________________________________
Policy Holder Name: ___________________________________________
Phone: (_____) ________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Liability: ____________________________________________________
UM BI: __________ UM PD: __________ Med Pay: __________________
6. PLAINTIFF'S PROPERTY DAMAGE INFORMATION - Add information to NAMES SCREEN 8
Year: ______________ Make: _____________________ Color: _______
License#: ______________________________ State:________________
Damage: _______________________________________________________
Estimate Amount: ______________________________________________
Registered Owner: _____________________________________________
Pictures (y/n): _______________________________________________
Location of Vehicle: __________________________________________
7. PLAINTIFF'S WAGE LOSS INFORMATION - Add information to NAMES SCREEN 8
Employer at Time of Accident: _________________________________
Phone: (_____)_________________________________________________
Position/Job Description: _____________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Supervisor Name: ______________________________________________
Phone: (_____)_________________________________________________
Was Time Lost (y/n)? : _________ How Much?: ___________________
Hr/Salary Wage: ___________________ Years at Job: _____________
>>>>>LINK PLAINTIFF NAME TO MATTER<<<<<
8. DEFENDANT'S PERSONAL INFORMATION - Add information to MATTERS SCREEN 7
Gender (m/f): __________________
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Home Phone: (_____)____________________________________________
Work Phone: (_____)____________________________________________
D. O. B.: _____________________________________________________
Year: ______________ Make: _____________________ Color: _______
License#: _____________________________ State:_________________
Damage: _______________________________________________________
Estimate Amount: ______________________________________________
Registered Owner: _____________________________________________
Passengers: ___________________________________________________
9. DEFENDANTS'S AUTO INSURANCE INFORMATION - Add information to MATTERS SCREEN 8
Company: ______________________________________________________
Coverage: _____________________________________________________
Address: ______________________________________________________
Phone: (_____) ________________________________________________
Agent: ________________________________________________________
Phone: (_____)_________________________________________________
Policy #: _____________________________________________________
Claim #: ______________________________________________________
Policy Holder Name: ___________________________________________
Phone: (_____) ________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Liability: ____________________________________________________
UM BI: __________ UM PD: __________ Med Pay: __________________
10. ACCIDENT INFORMATION - Add information to MATTERS SCREEN 9
Location: __________________________________ Time: ____________
Facts/Description : ___________________________________________
Injuries: _____________________________________________________
Purpose of Trip: ______________________________________________
Prior Accident Date:___________________________________________
Location: _____________________________________________________
Whose Fault: __________________________________________________
Other Party: __________________________________________________
Case Closed?:__________________________________________________
11. MEDICAL INFORMATION - Add information to MATTERS SCREEN 9
Emergency(y/n): __________ Ambulance (y/n): ___________________
Company: ______________________________________________________
Hospital: _____________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
>>>>>ADD DOCTORS TO NAMES DATABASE AND LINK TO MATTER<<<<<
Doctor #1
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Phone: (_____)_________________________________________________
Doctor #1
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Phone: (_____)_________________________________________________
12. WITNESS INFORMATION - Add information to MATTER SCREEN 10
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Home Phone: (_____)____________________________________________
Work Phone: (_____)____________________________________________
Pager/Cell: (_____)____________________________________________
Last Name: ____________________________________________________
First Name: ___________________________________________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Home Phone: (_____)____________________________________________
Work Phone: (_____)____________________________________________
Pager/Cell: (_____)____________________________________________
13. ADDITIONAL INFORMATION - Add information to MATTERS SCREEN 10
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
THESE MATERIALS HAVE BEEN PREPARED BY AC CONSULTING FOR INFORMATIONAL PURPOSES ONLY AND ARE NOT TECHNICAL ADVICE. YOU SHOULD NOT ACT UPON THIS INFORMATION WITHOUT SEEKING PROFESSIONAL TECHNICAL COUNSEL. THE ABACUS IN-TAKE SHEET SAMPLE IS FOR INFORMATION PURPOSES ONLY. THE ENTIRE RISK OF THE USE OR THE RESULT OF THE USE OF THIS ABACUS IN-TAKE SHEET SAMPLE REMAINS WITH THE USER. LIMITATION OF WARRANTIES AND LIABILITY:
THE SAMPLE IS PROVIDED ON AN "AS IS" BASIS, WITHOUT ANY OTHER WARRANTIES OR CONDITIONS, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF MERCHANTABLE QUALITY, SATISFACTORY QUALITY, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, OR THOSE ARISING BY LAW, STATUTE, USAGE OF TRADE, COURSE OF DEALING OR OTHERWISE. THE ENTIRE RISK AS TO THE RESULTS AND PERFORMANCE OF THE SAMPLE IS ASSUMED BY YOU. NEITHER WE NOR OUR DEALERS OR SUPPLIERS SHALL HAVE ANY LIABILITY TO YOU OR ANY OTHER PERSON OR ENTITY FOR ANY INDIRECT, INCIDENTAL, SPECIAL, OR CONSEQUENTIAL DAMAGES WHATSOEVER, INCLUDING, BUT NOT LIMITED TO, LOSS OF REVENUE OR PROFIT, LOST OR DAMAGED DATA OR OTHER COMMERCIAL OR ECONOMIC LOSS, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, OR THEY ARE FORESEEABLE. WE ARE ALSO NOT RESPONSIBLE FOR CLAIMS BY A THIRD PARTY. OUR MAXIMUM AGGREGATE LIABILITY TO YOU AND THAT OF OUR DEALERS AND SUPPLIERS SHALL NOT EXCEED THE AMOUNT PAID BY YOU FOR THE SAMPLE. THE LIMITATIONS IN THIS SECTION SHALL APPLY WHETHER OR NOT THE ALLEGED BREACH OR DEFAULT IS A BREACH OF A FUNDAMENTAL CONDITION OR TERM OR A FUNDAMENTAL BREACH. SOME STATES/COUNTRIES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU. |