Wrongful Death - New Client Initial Consult Form

Provide the following information for the person completing this form:

Name:(Required)

First Last

Today's Date:

Former Name(s):

Date of Birth:

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone:(Required)

Email:(Required)

Your Relationship to the Deceased Person:

Provide the following information for the deceased person:

Name:(Required)

First Middle Last

Former Name(s):

Date of Birth:(Required)

Social Security Number:(Required)

Last Home Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Circumstances of Death:

Date of Death:

Person(s) Who Caused Death:

Cause of Death:

Auto Collision

Malpractice

Other

Insurance Company of Person who Caused Death

Claim Number

Contact Person

Phone Number

Deceased's Spouse:

Did the deceased have a living spouse at the time of death?

Name of Spouse:

First Last

Date of Birth:

Social Security Number:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address:

Phone Number:

Employer:

Job Title:

Deceased's Children:

How many living children did the deceased have at the time of death?

First Child Name

First Last

First Child Date of Birth

First Child Social Security Number

First Child Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

First Child Phone

First Child Email

Second Child Name

First Last

Second Child Date of Birth

Second Child Social Security Number

Second Child Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Child Phone

Second Child Email

Third Child Name

First Last

Third Child Date of Birth

Third Child Social Security Number

Third Child Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Third Child Phone

Third Child Email

Additional Children

If the deceased had additional living children at the time of death, please provide for each additional child: Name, Date of Birth, Social Security Number, Address, Phone Number, Email Address

Deceased's Living Parents

Did the deceased have living parents at the time of death?

Mother's Name

First Last

Mother's Date of Birth

Mother's Social Security Number

Mother's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Phone

Mother's Email

Father's Name

First Last

Father's Date of Birth

Father's Social Security Number

Father's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Phone

Father's Email

Deceased's Will

Did the deceased have a will at the time of death?

Has the deceased's estate been opened?

Name of Administrator of Estate

First Last

Relationship to Deceased

Administrator's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Administrator's Phone

Administrator's Email

Name of Deceased's Family Law Attorney

First Last

Deceased's Insurance Information

Deceased's Health Insurance Company

Health Insurance Claim Number

Health Insurance Contact Person

Phone Number

Deceased's Auto Insurance Company

Auto Insurance Claim Number

Auto Insurance Contact Person

Phone Number

Deceased's Medical History

In this section we ask you to provide us information about the deceased’s medical treatment history and any conditions that the deceased had. Please include providers and conditions for the 10 years before death.

List of Medical Providers

For example: ambulances, hospitals, doctors/clinics, chiropractors, physical therapists, etc.

Medical Condition

Date of Diagnosis

Medical Providers Treating Condition

Additional Information

Provide any additional information here:

Please provide us any additional information you think we need to know or use this space to explain any of your answers in this questionnaire.

File Upload

It is NOT necessary for you to upload anything at this time, but if you have any files you would like to send to us, you may upload them here.

Drop files here or

Max. file size: 50 MB.

Wrongful Death – New Client Initial Consult Form

Provide the following information for the person completing this form:

Provide the following information for the deceased person:

Circumstances of Death:

Deceased's Spouse:

Deceased's Children:

Deceased's Living Parents

Deceased's Will

Deceased's Insurance Information

Deceased's Medical History

Additional Information