Roland A. Rosello Attorney at Law

Client Intake Form

NOTE: This Form is Best Completed on a Desktop or Laptop PC vs a Table or Mobile Phone. It is lengthy and Will take Some Time to Complete. Some Fields are MANDATORY and Require Input While Others Are Not. If You are Having Difficulty or Require Assistance Feel Free to Reach out to US at +1 (813) 251 – 8079 or Email Debbie@rolandarosello.com

Date *

Fields Marked with an * (Asterisk) are MANDATORY

CONFIDENTIAL CLIENT QUESTIONNAIRE

Thank you for your confidence in selecting Roland A. Rosello, P.L. to represent you in your personal injury claim. In order to most effectively represent you, we must obtain the following information. Please complete this form as fully as possible. All information provided to this law firm is protected by the attorney-client privilege. We appreciate your effort in completing this form. If this is a claim other than personal injury, please answer with your situation in mind, i.e. replacing your situation instead of auto or slip and fall.

Last Name: *
First Name: *
Middle Name: If None Please Write None *
Maiden Name/Alias/ Or Other Names That You Have:
Date of Birth: (MM/DD/YYYY) *
Social Security Number: (XXX-XX-XXXX) *
Drivers License/ID Number: *
Telephone Number Home: *
Telephone Number Work: *
Telephone Number Cell/Mobile: *
Telephone Number Fax:
Email Address for Correspondence: *
Home Address: (Street, Apt#, City, State, Zip Code) *
Mailing Address: (Street, Apt#, City, State, Zip Code) *
Name, Address and Telephone Number/s of a Person NOT Living with You to Contact in Case of Emergency: *

ACCIDENT or INCIDENT INFORMATION

Date and Time of Day of Accident or Incident: *
Location and Type of Incident: (Please be as Descriptive and Detailed as Possible *
Accident or Incident Details: (Please be as Descriptive and Detailed as Possible) *
Was Law enforcement Involved?: (Please enter Yes or No) *
If Law enforcement was Involved Which Department?:
Did Anyone Receive a Ticket as a Result of This Accident?:
Were There Any Passengers In Your Vehicle?: (Please Answer Yes or No)
If so, Please List the Name/s, Address/es, and Telephone Number/s of Each Passenger:
Do You Know if There Were Any Witness/es to the Accident or Incident?:
If So, Please List the Name/s, Address/es, and Telephone Number/s of Each Witness/es:
Please Provide Us ANY Statement/s That You Heard the Defendant Make About the Incident, or That You Understand That He/She May Have Made:
In Detail, Please Describe ALL Injuries That You Sustained as a Result of the Incident:
Did an Ambulance Transport You to the emergency Room?: (Please Answer Yes or No)
Were X-rays taken at the Hospital: (Please Answer Yes or No)
What is the Name, Address and Telephone Number of the Hospital that You were Taken to?
Please list ALL of the Doctors and ANY Other Medical Facilities That You Have Been to as a Result of the Accident (Include Address and Telephone Number, if Known):
In Detail, Please Describe the Damage Done to Your Vehicle:
Has Your Vehicle Been Considered a Total Loss by Anyone?: (Please Answer yes or No)
Where is Your Vehicle Now?:
Please Describe the Damage done to Other Vehicle/s:
Has Anyone Taken Photographs of Your Vehicle or Any Other Vehicle Involved in the Accident?: (Please Answer Yes or No)
If Yes, Who Took the Photos?: (Please Include Name/s, Address/es and Telephone Number/s of each Person/s)
Has Anyone Taken Photographs of the Scene Where the Incident Happened (Slip and Fall, et cetra) Please Answer Yes or No?:

EMPLOYMENT INFORMATION

Name of Your Employer at the Time of the Incident: *
How Long Have/Had You Worked for This Employer Prior to the Incident?:
What was Your Job title at the Time of This Incident?:
What was Your Rate of Pay or Compensation at the Time of This Incident?:
Have You Missed ANY Time From Work as a Result of This Incident?: (Please Answer yes or No)
If Yes, Please List the Dates and The Reason/s for Being Unable to Work:
Did You Lose ANY Wages as a Result of Being Unable to Work?: (Please Answer Yes or No)
If so, What was the Total Amount of Lost Wages at This Time?:
Have You Used ANY Vacation or Sick Time to Avoid Losing Wages?: (Please Answer Yes or No)
Have You Changed Jobs Since the Incident?: (Please Answer yes or No)
If Yes, Please Explain Why and The Name and Address of Your New Employer:

AUTO INSURANCE INFORMATION (For Auto Cases Only)

Do you Know Whether the Person/Business Causing Your Injuries Was Covered by ANY Type of Insurance?:
If yes, What is the Name of the Insurance Company?:
If a Claim was Filed, What is the Claim Number?:
Have You Spoken to Anyone From The Insurance Company?: (Please Answer yes or No)
Did Anyone take a Recorded Statement From You?: (Please Answer yes or No)
What is/was the Name of YOUR Automobile Insurance Company at the Time of the Accident?:
Have You Notified Your Automobile Insurance Company of This Accident?: (Please Answer yes or No)
What is the Telephone Number of YOUR Automobile Insurance Company’s Claims Department?:
What is YOUR Automobile Insurance Policy Number at Time of This Incident?:
Has Your Automobile Insurance Company Provided You with a Claim Number?: (Please Answer Yes or No)
Have You Completed a PIP Application?: (Please Answer Yes or No)
Have You made a Claim to YOUR Automobile Insurance Company for Lost Wages?: (Please Answer Yes or No)

HEALTH INSURANCE INFORMATION

Were You Covered by ANY Type of HEALTH INSURANCE at the Time of Your Accident or at Anytime Since Your Accident?: (Please Answer Yes or No)
If Yes, what is the Name of the Health Insurance Company?:
What is the Health Insurance Policy Number and the Type of Coverage: (PPO, HMO, MEDICARE, MEDICAID)
What is the Telephone Number to Your Health Insurance Provider’s Claims Department?:

SPOUSE INFORMATION

What is Your Spouse’s Full Name, Age and Date of Birth?:
How Long Have You Been Married?:
What is Your Spouse’s Occupation?:
What is Your Spouse’s Place of Employment?:
Client Name:
Client Initials: