New Client Intake Form Please answer all sections that apply to you so that our Kelowna lawyers can better understand your legal options. DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referred ByHow did you hear about us?Name First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code 1) Phone Number1) Phone Number TypeHomeWorkCellOther2) Phone Number2) Phone Number TypeHomeWorkCellOther3) Phone Number3) Phone Number TypeHomeWorkCellOtherFax NumberFax Number TypeHomeWorkOther1) Email 1) Email TypeHomeWorkOther2) Email 2) Email TypeHomeWorkOtherDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Personal Health No.Social Insurance No.AccidentDate of AccidentMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of Accident : HH MM AM PM Location of AccidentDriver's License #Make, Model & License Plate # of Your VehicleICBC or Other Insurer Claim #Adjuster's Name First Last Adjuster's Phone #Emergency Vehicles in AttendanceCheck all the apply Ambulance RCMP Fire Truck RCMP File #Your Position in the AccidentDriverFront Seat PassengerRear Seat Passenger (Driver Side)Rear Seat Passenger (Passenger Side)Rear Seat Passenger (Center)Passenger (Other)CyclistPedestrianNames of the other people in your vehicle and where they were seated in the vehicleNames of all the other people involved in the accident and their positions in their vehicleNames and contact information of all witnesses that you are aware ofDescription of other vehicles involved including year, make, model * license plate number(if other than BC please advise)Details of how the Accident occurredInjuriesFirst Medical Care ReceivedOther than at the sceneHospitalWalk-In ClinicFamily DoctorHospital NameWere you transported by ambulance to the hospital?YesNoWalk-In Clinic NameName of Family Doctor First Last Doctor's Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Doctor's Phone #How long have you been a patient of this doctor?Description of ALL injuries sustained in the AccidentDescription of any pre-existing health conditionsDescription of any treatment received for injuries from this AccidentFor example: medication, physiotherapy, massage therapy, chiropractor, etc.Names & contact information for any additional medical professionals or care providers seen as a result of the AccidentList of things you CANNOT do as a result of this AccidentList of things that you can do but find more difficult to do as a result of this AccidentHave you been involved in a car accident beforeYesNoWhen did it/they occur and what injuries did you suffer, if any?Have you been involved in any other type of accident beforeeg. work, sport etc.YesNoWhen did it/they occur and what injuries did you suffer, if any?Name of spouse and dependants with their agesEmployment InformationWere you performing work related duties at the time of the Accident?YesNoNot SureIf so, what were you doing?For example: delivering product, attending an appointment, etc.Employer NameEmployer's Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Employer's Phone #Date you started working for this EmployerMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Job TitleCurrent Wage/Salary per month or hourTime missed from work due to AccidentTotal hours normally worked per weekSick Leave entitlementSupervisor'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 AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code 1) Previous Employer's Phone #1) Date employment with previous Employer endedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201) Previous Wage/Salary1) Supervisor’s Name with previous Employer First Last 2) Previous Employer2) Previous Employer's Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code 2) Previous Employer's Phone #2) Date employment with previous Employer endedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202) Previous Wage/Salary2) Supervisor’s Name with previous Employer First Last 3) Previous Employer3) Previous Employer's Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code 3) Previous Employer's Phone #3) Date employment with previous Employer endedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119203) Previous Wage/Salary3) Supervisor’s Name with previous Employer First Last Name & Location of School & dates attendedIf currently enrolledWere the injuries sustained in the course of employment?YesNoAt 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 InsuranceName Health Insurance ProviderPlan No. of Health InsuranceBring 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 ProviderInsurance Benefits You Have Applied ForCheck 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 ForEvidenceDocuments/evidence in your possessioncheck all that apply and bring these items with you if filling out this form in advance of your appointment police report notes made by you or others at the scene of the accident notes made by you after the accident business cards received from police officers, witnesses or other people involved correspondence from ICBC or other insurers receipts for expenses relating to the accident damaged clothing or property photographs of the scene of the accident photographs of your vehicle and/or the other vehicle(s) after the accident photographs of your injuries video footage of accident scene, injuries or recovery diagrams/drawings of accident scene or injuries medical devices used in treatment (Example: sling, pins, screws, braces, etc.) documents provided to you by treating physicians (Example: exercises, prescriptions, etc.) income tax returns from before (three previous years) and after the date of the accident EI, CPP, or other insurance application forms submitted as a result of this accident and related correspondence other income or employment information, including resumes and job applications around the time of the accident any other documentation relating to the accident Additional CommentsUse 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.