Personal Injury Intake Form

Call: (918) 582-7775
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  The Gorospe Law Group Personal Injury Law Firm in Tulsa is experienced in all types of personal injury areas. If you or a loved one has been injured due to the negligence of another, contact us today!
  
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GOROSPE LAW GROUP

Protecting personal information that we collect from you is a top priority at the Gorospe Law Group. Using 2048-bit encryption protects the information by scrambling it as it is sent from your computer or device to our website. It helps to keep your information secure and private.

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Emergency Contact

Emergency Contact Phone

Date of Accident

Location of Accident

Describe how the accident occurred.

List any witnesses to the accident:

Describe any communication you had with anyone at the scene (witnesses, staff, bystanders, law enforcement, paramedics, etc.) :

Describe your injuries suffered from the accident:

Was an ambulance called to the scene?

Yes

Were you taken to a hospital by ambulance?

Yes

What ambulance provider?

List all medical providers seen since the accident and approximate dates seen:

Prior to this accident have you ever injured or sought medical treatment for the same or similar body parts injured in this accident?

Yes

Have you been involved in any prior insurance claims, including worker’s compensation claims? Y/N If yes, please explain providing approximate dates:

Have you missed work due to your injuries from this accident?

Yes

Provide the name of the medical provider, if any, who excused you from work

Where are you employed?

How long employed at current employment?

Salary/Wages?

What is your job title?

What are your job duties?

Name of your immediate supervisor

If a claim has been made to any insurance company regarding the accident, please provide the following:

Adjuster name

Claim Number

Adjuster Address

City State / Province / Region ZIP / Postal Code Country

Adjuster phone number

Adjuster fax number

Your health insurance information:

Health Insurance Company

Subscriber ID

Group ID:

Do you receive Medicare?

Yes

Medicare Number and Info

Do you receive Medicaid (Soonercare)?

Yes

Medicaid Number and Info

Did you take photos of the accident scene?

Yes

Did you take photos of your injuries?

Yes

Photo Uploads

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Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

You may upload multiple images here, although file size may be limited. Please only upload jpg, gif, png, or pdf format.

Any additional information regarding your case not already covered?

How did you hear about our law office?

Comments

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GOROSPE LAW GROUP

The Gorospe Law Group Personal Injury Law Firm in Tulsa is experienced in all types of personal injury areas including car accidents, motorcycle accidents, commercial trucking accidents, premise liability, medical malpractice and more.

CONTACT US

1825 E 15th St
Tulsa, OK 74104
Phone: (918) 582-7775
Web: Gorospe Law Group

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