Vanderpool Griffith LLP

401 B Street, Suite 2000
San Diego, CA 92101

Injury/Death Case Questionnaire

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact Information

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Case Information

Is this a death case?

Yes

Briefly describe how the death/injury happened:

Describe the injury, including the parts of the body injured:

Alleged Defendant

Who do you believe is to blame for the injury or death?

Identify by name and address, if known

Employer:

Another Person/Company:

Doctor/Hospital/Medical Provider:

Causes of Injury/Death

Were any of the following involved in the causing the injury or death? Describe.

Dangerous Product:

Faulty Equipment:

Unsafe Property Condition:

Other:

Additional Case Information

Was anyone else injured or killed in the same accident?

Were there any witnesses?

Yes

Do you have any pictures of the accident scene or your injuries?

Yes

Did the police, Highway Patrol, OSHA or other agency make a report?

Yes

If this injury or death occurred at work, was it reported to the employer?

Yes

Has a workers compensation claim form been submitted to the employer?

Yes

Did the injury or death occur at work or was the decedent employed at the time death?

Yes

If this is an injury claim, have you missed work because of the injury?

Yes

If this is a death case, did the decedent receive medical care before death?

Yes

If this is an injury case, have you received medical care?

Yes

Has any surgery been performed or scheduled?

Yes

Did you or the decedent have health insurance?

If this was a vehicle accident involving your vehicle, do you have Auto Insurance?

Are you currently representing by another attorney?

Yes

THANK YOU

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