Attorney Intake Form: Airline Personal Injuries

People are killed or seriously injured in airplane crashes every year. In other situations, an airline passenger may twist his or her back trying to put a piece of luggage in an overhead bin, or be burned by spilled coffee from the service cart during a particularly rough patch of turbulence. If you have been injured while on an airplane, you might retain the services of an attorney. This intake form may help answer those questions.

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Intake Form: Airline Personal Injuries

 

Name _____________________________

 

Date of Birth _______________________

 

Social Security Number __________________

 

Address, Including County:

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Length of Time at that Address:  _______ years       _______ months

 

Previous Address(es) (for last 10 years):

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Home Telephone Number:      ____________________

 

Work Telephone Number:       ____________________

 

Facsimile Number:                  ____________________

 

E-mail Address:                      ____________________

 

Former Name(s):                    ____________________

 

Current Employer:                   ____________________

 

Position:                                    ____________________

 

Employer’s Address:

______________________________

______________________________

______________________________

 

Length of Time with Employer:  _______ years

 

Previous Employer(s) (for last 10 years):

______________________________            ______________________________

______________________________            ______________________________

______________________________            ______________________________

______________________________            ______________________________

 

Gross Monthly Income:  $_________________

 

Marital Status: __________________________

 

Previous Marriage(s):  Yes  ____   No  ____ How Ended?_________________

 

Children

 

Name                           Date of Birth   Living in home?         

_______________      _________      _______________     

_______________      _________      _______________     

_______________      _________      _______________     

_______________      _________      _______________     

 

Dates of Travel: _________________________________

 

Purpose for Travel: _______________________________

 

Travel Agency Used: _____________________________Yes/No

 

Name  ___________________________________

 

Address __________________________________

                __________________________________

                __________________________________

 

Airline: _________________________________________

 

Flight Number: ___________________________________

 

Departure City: ___________________________________

 

Arrival City: _____________________________________

 

Date of Injury: ____________________________________

 

Approximate Time of Injury: ________________________

 

Description of How Injury Occurred:

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Names and Addresses of Witnesses to Injury, If Known:

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Injury Reported to Airline ___________Yes/No

When________________________________________

To Whom _____________________________________

 

Additional Contact with Airline __________________________________________________________________

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Description of Immediate Medical Attention Received Including Names and Locations of Providers:

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Description of Subsequent Medical Attention Received Including Names and Locations of Providers:

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Current Medical Condition:

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Any Surgeries Performed or Scheduled As a Result of Injury:

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Previous Medical History:

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Any History of Similar/Same Injuries:

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Does Injury Prohibit Performance of Any Daily Living Activities (Examples: Can you brush your hair? Dress yourself? Drive a Car?)

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Time Lost From Work Since Injury_______________Yes/No

Amount of Time Lost Including Specific Dates, If Known:

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Hobbies/Interests:

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Does Injury Prevent You From Engaging In These Hobbies/Interests?__________ Yes/No

 Explain ___________________________________________________________

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Other Important Information:

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Questions to Ask My Attorney:

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Getting Legal Help

Airline injuries can have series implications for victims, including extensive recovery time spent away from work. An injury lawsuit can allow you to recover compensation for your medical expenses, lost wages, and pain and suffering. However, navigating an airline injury suit is a complicated task. The first step is to learn more about your claim. Contact an experienced injury attorney today for a free claim evaluation.

Next Steps

Contact a qualified personal injury attorney to make sure your rights are protected.

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