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

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________



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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.

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