PLG Intake Form

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Full Intake - English

Contact Information:
Full Name:*
First Last
Please provide a picture of yourself for our online case management system:
Accepted file types: jpg, jpeg, png, gif.
Preferred Name/Nickname:
Name you go by...
Email Address:*
Mobile Phone:*
Preferred Contact Method:
- Phone Call
- Text Message
- Email
Best Callback Time:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
SSN:*
This is required to obtain your medical records.
Date of Birth:*
Driver's License Number:
Driver's License State:
Upload photo of your Driver's License:
Accepted file types: jpg, jpeg, png, gif.
Driver's License ever revoked?
- Yes
- No
- Unknown
License Revocation Explanation:
Have you ever been convicted of a crime?
- Yes
- No
- Unknown
Crime Explanation:
Have you ever or are you planning to file for bankruptcy?
- Yes I have
- No
- Planning To / Maybe / Not Sure
- Unknown
Bankruptcy Explanation:
Marital Status:
- Married
- Single
- Divorced
- Widowed
- Other
Spouse Name:
First Last
Spouse Phone:
Married for how long?
Emergency Contact:
- Spouse
- Other
Emergency Contact Name:
First Last
Emergency Contact Phone:
Children/Grandchildren?
- Yes
- No
- Unknown
How many Children / Grandchildren?
Do you have an active Child Support Case or Child Support Lien?*
*Legally required for any Settlement Disbursement*
- Yes
- No
Amount of Child Support Lien:
Agency holding Child Support Lien/Case:
Are you a Veteran?*
- Yes
- No
Date of Discharge:
Thank you for your service!
Incident Information
Type of Incident:*
Date of Incident:*
Approximate Time of Incident:*

: Hours

Minutes

AM/PM
Location of Incident:
What was the purpose of your trip?
Please describe in detail what you remember about the incident:*
Position in vehicle:*
- Driver in vehicle owned by you
- Driver of vehicle owned by other person
- Passenger of vehicle owned by you
- Passenger of vehicle owned by other person
Does the owner of the vehicle have insurance on it?*
- Yes
- No
- Unknown
Were you wearing a helmet?
- Yes
- No
- Unknown
Have you ever suffered a dog bite prior to this incident?
- Yes
- No
- Unknown
Please explain when you suffered a dog bite previously, your age and details:
Year, Make & Model of your vehicle/vehicle you were in:
Amount of miles:
Is the vehicle operable?
- Yes
- No
- Unknown
Was the vehicle towed from scene?
- Yes
- No
- Unknown
Current location of vehicle:
Hidden
Please upload any photos you have of the damage to your vehicle/the vehicle you were within:
Drop files here or

Max. file size: 50 MB.
Please upload a photo you have of the damage to your vehicle/the vehicle you were within:
Max. file size: 50 MB.
Hidden
Please upload any photos you have of the damage to your vehicle/the vehicle you were within:
Max. file size: 50 MB.
Hidden
Please upload any photos you have of the vehicle that caused the accident:
Drop files here or

Max. file size: 50 MB.
Please upload a photo you have of the vehicle that caused the accident:
Max. file size: 50 MB.
Hidden
Please upload any photos you have of the vehicle that caused the accident:
Max. file size: 50 MB.
Who is the registered owner of the vehicle you were in during the incident?
If other than yourself, please provide name, relation and phone number.
Were any other people in the vehicle?
- Yes
- No
- Unknown
Who and in what position?
Please provide name, relation and phone number.
Did you see the wreck coming?
- Yes
- No
- Unknown
In what manner?
Did you brace for impact?
- Yes
- No
- Unknown
With what parts of your body did you brace for impact?
Did the airbags deploy?
- Yes
- No
- Unknown
Did you suffer any abrasion or contact with the airbags and to where?
Did you have a seatbelt on at the time of impact?
- Yes
- No
- Unknown
Did you suffer any abrasion or bruising from the seatbelt and to where?
Describe your body position at the moment of impact (facing forward, twisted left/right, etc.):
Did you speak to the other driver after the incident?
- Yes
- No
- Unknown
Please provide details regarding that conversation:
Do you know if the other driver was on their cell phone?
- Yes
- No
- Unknown
How do you know or believe they were on their phone?
Do you have reason to believe the other driver was on the job at the time of the incident?
- Yes
- No
- Unknown
How do you know or believe they were on the job?
Do you know if the other driver was intoxicated?
- Yes
- No
- Unknown
How do you know or believe they were intoxicated?
Did the incident take place in a construction zone?
- Yes
- No
- Unknown
Please explain how it was in a construction zone:
Can anything besides the other driver possibly be blamed for the wreck (weather, mechanical problems, your own driving/actions, etc.)?
- Yes
- No
- Unknown
Please elaborate on any other factors that could be blamed:
Were the police notified/on site?
- Yes
- No
- Unknown
Who notified the police?
Were any citations issued?
- Yes
- No
- Unknown
If yes, who received a ticket and what for?
Is there a police report?
- Yes
- No
- Unknown
Police report number:
If you have the police report, please uplod here:
Drop files here or

Max. file size: 50 MB.
Hidden
If you have the police report, please upload here:
Max. file size: 50 MB.
Were you on the job at the time of the incident?
- Yes
- No
- Unknown
Were you within the scope of normal employment and what duties were you executing at the time?
Were there any witnesses to the incident?
- Yes
- No
- Unknown
Please provide as much detail as you can about any witnesses; including name and contact information.
If you spoke to any of the witnesses, please describe all of those conversations in detail as best you can and note with whom you spoke.
Have you or anyone to your knowledge posted anything about this incident on social medial? If so, please describe what was posted.
Please list all social media platforms you use (e.g. Facebook, Instagram, Twitter/X, etc.) and provide your username/handle for all.
Do you believe the incident was, or may have been captured on video? If so, provide any information you have that would assist us in trying to obtain the video footage.
Were there any other injured parties as a result of the incident?
- Yes
- No
- Unknown
Please provide names, as well as any other information you may have regarding other injured parties.
Medical Information
Injured Body Parts:
- Ankle - Left
- Ankle - Right
- Anxiety
- Arm - Left
- Arm - Right
- Broken Bone
- Chest
- Concussion
- Depression
- Ear - Left
- Ear - Right
- Ear - Ringing
- Elbow - Left
- Elbow - Right
- Face
- Foot - Left
- Foot - Right
- Hand - Left
- Hand - Right
- Head
- Hip - Left
- Hip - Right
- Jaw
- Knee - Left
- Knee - Right
- Leg - Left
- Leg - Right
- Mental/Emotional
- Neck
- Nose
- Ringing Ears
- Shoulder - Left
- Shoulder - Right
- Spine - Cervical
- Spine - Lumbar
- Spine - Thoracic
- Surgery
- Teeth
- Traumatic Brain Injury
- Wrist - Left
- Wrist - Right
- Other
Mental/Emotional - Explain:
Surgery - Explain & to which body parts:
Broken Bone - Explain & to which body parts:
Traumatic Brain Injury - Explain & to which body parts:
Other - Explain:
Out of any body parts injured in this incident, were any of those in pain immediately prior to the incident? (e.g. 'I hurt my shoulder in the accident, but it was already in pain from a prior separate injury unrelated to the wreck')
- Yes
- No
- Unknown
Please explain:
Have you dealt with any injuries or issues in the past with any of the areas injured in this incident? (e.g. 'I hurt my knee in the accident, but also injured it in an unrelated incident three years ago')
- Yes
- No
- Unknown
Prior/Other Injury - Explain:
Did you go to the hospital after the incident?
- Yes; immediately by ambulance/careflight/EMS.
- Yes; immediately after by someone other than EMS.
- Yes; but not immediately.
- No; I have not been to the hospital for this.
Have you set up online portal access for the hospital you were treated at?
- Yes
- No
- Unknown
If yes, please provide below. If not, can we set up access on your behalf?
*This helps to expedite retrieval of records*
Do you believe you lost consciousness at the scene?
- Yes
- No
- Unknown
Why do you believe so and for how long do you believe you were unconscious?
Please list all the ways your injuries have impacted your daily life: (e.g. can't play with kids, difficult to get dressed, can't perform basic hygiene tasks, unable to participate in regular hobbies and what those were, etc.)
Do you have any bruises? If so, where?
Hidden
Please upload a photo of your injuries/bruises you may have.
Continue to document your injuries/bruises and your case manager will regularly check in with you to obtain.
Drop files here or

Max. file size: 50 MB.
Please upload a photo of your injuries/bruises you may have.
Continue to document your injuries/bruises and your case manager will regularly check in with you to obtain.
Max. file size: 50 MB.
Hidden
Please upload any photos of your injuries/bruises you may have.
Continue to document your injuries/bruises and your case manager will regularly check in with you to obtain.
Max. file size: 50 MB.
Please list any physicians you have been or are currently seeking treatment with regarding your injuries from this incident:
If you are not currently seeing any doctors, would you like our help in finding a doctor to treat you for your injuries? If so, in which general area are you located (e.g. Fort Worth, San Antonio, Dallas, etc.)?
Primary Care Provider's name and phone number:
Do you have online access to your PCP records? If so, please provide credentials. If not, may we set up access on your behalf?*
*This allows for expedited retrieval of necessary records as able*
Please list any other medical conditions you are currently receiving treatment for, or have received treatment for in the past 5 years, including mental care.
Employment Information:
Were you employed at the time of the incident?
- Yes
- No
- Unknown
Employer Name:
Occupation:
Type of Employment
- W2
- Self Employed
- 1099 Employee
Is your income reported and taxes filed for any lost wages to be able to be supported with clear documentation?
- Yes
- No
- Unknown
Hire date & time employed:
Pay amount and frequency:
Employer/Work Address
Street Address Address Line 2 City State ZIP Code
Employer/Work Phone Number:
Have you lost time from work as a result of this incident?
- Yes
- No
- Unknown
Did you use any sick time or other leave to cover your time missed from work as a result of this incident?
- Yes
- No
- Unknown
Please list all time you have missed from work: (Please include all time missed but specify whether time was unpaid, or if vacation/sick leave was utilized)
Is there anything else you think we should know about your employment and/or how this incident has impacted your earning capacity?
Defendant's Information
(I.E. The Person or Place responsible for your incident)
Defendant's Name:
Defendant License Number & State:
Year, Make & Model of Defendant's Vehicle:
Did the at-fault driver have auto insurance?
- Yes
- No
- Unknown
Please provide insurance information for the at-fault driver.
Include name of policy holder, their insurance company and any other relevant information you may have.
Has a claim been established with the Defendant Insurance and/or have you spoken with any Adjustor or Representative?
- Yes
- No
- Unknown
Claim Number:
Name & Contact Info of Adjustor or Representative:
Has liability already been accepted by the Defendant's insurance company? If no, are they disputing liability?
In speaking to the adjuster or representative, did you give a recorded statement? Please provide details of any conversations you have had as best you can.
Client/Your/Other Insurance Information:
Has a claim already been reported/opened with your/vehicle owner's insurance?
- Yes
- No
- Unknown
Name of Company claim was reported/opened up with:
Claim Number:
Name and Contact info of your Insurance Adjustor
Vehicle Owner Insurance: (Company, Policy Holder Name, Policy Number & any other relevant details)
Do you have insurance on your personal vehicle?
- Yes
- No
- Unknown
Your Insurance Information: (Company, Policy Holder Name & Phone Number)
Has your insurance/vehicle owner's insurance resolved the property damage claim for your vehicle? If yes, have they reimbursed for any relevant deductibles yet?
If you have not received your deductible, please specify if you would like help obtaining.
Do you have Uninsured/Underinsured Motorist Coverage and do we have permission to start a claim under this coverage?
- Yes
- No
- Unsure - Would like to discuss
Do you have Personal Injury Protection Coverage and do we have permission to start a claim under this coverage?
- Yes
- No
- Unsure - Would like to discuss
Have you spoken to an adjuster for insurance other than the defendant's and or given a recorded statement? If so, please describe that conversation in as much detail as able.
Please upload a picture of the Declarations page of your auto insurance policy:
Drop files here or

Max. file size: 50 MB.
Hidden
Please upload a picture of the Declarations page of your auto insurance policy:
Max. file size: 50 MB.
Owned, Financed or Leased:
- Owned (You are the title holder)
- Leased - If so - Lienholder?
- Financed - If so - Lienholder?
- Other Owner - If so - who?
Lienholder or Other Owner?
Do you have a preference on body shop if your vehicle is repairable?
Did you have any other personal property (e.g. car seats, cell phone, clothing, etc) that was damaged as a result of the incident? (If yes, the items will require both proof of damage as well as receipts/proof of initial purchase:
Do you have health insurance?
- Yes
- No
- Unknown
Hidden
Please upload pictures of the front and back of your health insurance card. If you do, you can skip the next question.
Drop files here or

Max. file size: 50 MB.
Please upload a picture of the front of your health insurance card.
Max. file size: 50 MB.
Please upload a picture of the back of your health insurance card. If you uploaded both front and back you can skip the next question.
Max. file size: 50 MB.
Hidden
Please upload pictures of the front and back of your health insurance card. If you do, you can skip the next question.
Max. file size: 50 MB.
Please list the name of your health insurance provider, group ID number, plan ID number, and the telephone numbers found on the back of the card. (If the primary plan holder is other than yourself, include the Plan Holders Full Name, DOB & SSN)
If you have received any medical treatment as a result of your injuries sustained in the incident, have your medical providers been submitting your treatment through your health insurance?
Hidden
Who is the primary plan holder for the health insurance? Please include their full name and social security number.
Hidden
Primary Plan Holder's Date of Birth:
Are you Medicare, Medicaid or CHIPS eligible? If so, which one?
Do you have Part A, Secondary Medicare, etc.? Is so, which one?
Are you disabled?*
- Yes
- No
Date of Disability Diagnosis:
Percentage of disability:
Currently treating for your disability?
- Yes
- No
- Unknown
With whom and for what symptoms are you treating regarding your disability:
General Information:
If inapplicable, please enter N/A.
List all injury-causing incidents you have been involved in the past (e.g. car wrecks, slip and falls, etc.). Please describe each in detail.
List any Workers' Compensation claims you have made, including the names of your employers, when the claim occurred, incident details and injuries for any and all.
Prior to this incident, what activities or hobbies did you perform/enjoy on a regular basis?*
Please provide the name, relationship to you and phone number of up to 4 "impact witnesses" (people that are close to you that would be able to describe the impact of your injuries on your daily life).
Is there any additional information that we need to know about this incident or about you that we haven't asked yet?
List any and all lawsuits you have ever been involved with previously along with relevant details.
How did you hear about us?
If you were referred to us by an individual or other, please list their first and last name, or organization as well as their phone number or email and how you heard of us from them.
Does your case involve loss of life, a catastrophic injury, or broken bones?*
- Yes
- No
- Unknown

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PLG Intake Form

Full Intake - English

Contact Information:

Thank you for your service!

Incident Information

Medical Information

Employment Information:

Defendant's Information

Client/Your/Other Insurance Information:

General Information: