New Client Intake Forms | Doak Shirreff Lawyers LLP

Date

Referred By

How did you hear about us?

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Personal Information

1) Phone Number

1) Phone Number Type

2) Phone Number

2) Phone Number Type

3) Phone Number

3) Phone Number Type

Fax Number

Fax Number Type

1) Email*

1) Email Type

2) Email

2) Email Type

Date of Birth

Personal Health No.

Social Insurance No.

Accident

Date of Accident

Time of Accident

:

Location of Accident

Driver's License #

Make, Model & License Plate # of Your Vehicle

ICBC or Other Insurer Claim #

Adjuster's Name

First Last

Adjuster's Phone #

Emergency Vehicles in Attendance

Check all the apply

Ambulance
RCMP
Fire Truck

RCMP File #

Your Position in the Accident

Names of the other people in your vehicle and where they were seated in the vehicle

Names of all the other people involved in the accident and their positions in their vehicle

Names and contact information of all witnesses that you are aware of

Description of other vehicles involved including year, make, model * license plate number

(if other than BC please advise)

Details of how the Accident occurred

Injuries

First Medical Care Received

Other than at the scene

Hospital Name

Were you transported by ambulance to the hospital?

Yes
No

Walk-In Clinic Name

Name of Family Doctor

First Last

Doctor's Address

Street Address Address Line 2 City Province Postal Code

Doctor's Phone #

How long have you been a patient of this doctor?

Description of ALL injuries sustained in the Accident

Description of any pre-existing health conditions

Description of any treatment received for injuries from this Accident

For example: medication, physiotherapy, massage therapy, chiropractor, etc.

Names & contact information for any additional medical professionals or care providers seen as a result of the Accident

List of things you CANNOT do as a result of this Accident

List of things that you can do but find more difficult to do as a result of this Accident

Have you been involved in a car accident before

Yes
No

When did it/they occur and what injuries did you suffer, if any?

Have you been involved in any other type of accident before

eg. work, sport etc.

Yes
No

When did it/they occur and what injuries did you suffer, if any?

Marital Status

Name of spouse and dependants

Ages of spouse and dependants

Employment Information

Were you performing work related duties at the time of the Accident?

Yes
No
Not Sure

If so, what were you doing?

For example: delivering product, attending an appointment, etc.

Employer Name

Employer's Address

Street Address Address Line 2 City Province Postal Code

Employer's Phone #

Date you started working for this Employer

Your Job Title

Current Wage/Salary per month or hour

Time missed from work due to Accident

Total hours normally worked per week

Sick Leave entitlement

Supervisor's Name

First Last

1) Previous Employer

(if less than 12 months at current job)

1) Previous Employer's Address

Street Address Address Line 2 City Province Postal Code

1) Previous Employer's Phone #

1) Date employment with previous Employer ended

1) Previous Wage/Salary

1) Supervisor’s Name with previous Employer

First Last

2) Previous Employer

2) Previous Employer's Address

Street Address Address Line 2 City Province Postal Code

2) Previous Employer's Phone #

2) Date employment with previous Employer ended

2) Previous Wage/Salary

2) Supervisor’s Name with previous Employer

First Last

3) Previous Employer

3) Previous Employer's Address

Street Address Address Line 2 City Province Postal Code

3) Previous Employer's Phone #

3) Date employment with previous Employer ended

3) Previous Wage/Salary

3) Supervisor’s Name with previous Employer

First Last

Name & Location of School & dates attended

If currently enrolled

Were the injuries sustained in the course of employment?

Yes
No

At the time of the accident, where were you travelling from?

At the time of the accident, where were you travelling to?

Have you applied for

WCB benefits
EI benefits

Insurance

Name Health Insurance Provider

Plan No. of Health Insurance

Bring copy of benefit plan booklet with you to our initial meeting so we can review plan coverages with you.

Name of Short Term/Long Term Disability Provider

Insurance Benefits You Have Applied For

Check all that apply

Employment Insurance (also known as unemployment insurance)
Canada Pension Plan – Disability
ICBC – Part 7
Private insurance through employer or family member
WCB
Other

Other Insurance Benefits Applied For

Evidence

Documents/evidence in your possession

check all that apply and bring these items with you if filling out this form in advance of your appointment

Additional Comments

Use this page if more space is required or if additional comments/circumstances need to be mentioned

*Please note that until such time as we have been able to run a conflict search to confirm that we are not in a conflict of interest with our existing clients we are unable to receive and review any confidential information from you. Accordingly, please only provide the nature of the issue (ie. personal injury, family law, estate litigation, business law, real estate, wills & estates etc.) and the names of the parties involved, without additional, fact-specific details about your case.

Client Intake