INSTRUCTIONS:

The first stage of your lawsuit is called the DISCOVERY PERIOD. Discovery is the part of your case where we provide information to the insurance company about your background and information about the accident itself.  You are required to answer each and every question on this questionnaire (Please list N/A for any and all questions that do not apply to you).

Please answer each question as if you were under oath in a courtroom in front of a judge.  If your answers are not complete and truthful you will lose your case.

You may call our office at (770) 633-0007 if you have any questions about the information you need to provide or to discuss why the insurance company is asking you to provide this information – Even though the questions are personal they are entitled to know everything about your personal and medical background since you are filing a lawsuit for injury. 

BACKGROUND/PERSONAL INFORMATION

Current Home Address (Include City, State, ZIP Code, and Apartment or Suite # if applicable:

Do you live with anyone else over the age of 18?  If so, please provide the full name of all persons over the age of 18 who live with you:

List all prior addresses last ten (10) years, and the approximate dates you lived at each address:

Were you using your cell phone at the time of the accident for any reason (texting, making a call, streaming music through Bluetooth, etc.)  The insurance company will order your cell phone records to verify.  If YES, please provide information on how you were using the phone at the time of the crash (Example:  I was streaming music to my radio, or I was making a hands-free phone call, or I was sending a text message):

Did you post or create ANY social media content (written posts, photos, stories, videos, etc.) about this accident on any social media site (including Facebook, Twitter, Instagram, Snapchat, TikTok, and YouTube)  If YES, you must provide a screenshot of each post and all comments under the post.  Failure to provide screenshots of all posts may result in a loss of your case:

Have you ever filed for bankruptcy?  If YES, please provide: the year you filed; (b) the city where you filed; the type of bankruptcy you filed and (d) if your bankruptcy was completed, is still ongoing, or if you dismissed the claim before it was finalized.
Example:  2014, Chapter 7, Atlanta Bankruptcy Court, Discharged in 2015

Have you traveled outside of the State of Georgia since this accident for any reason (vacation, work, etc.)?  Please provide:  The destination, the purpose of your trip, method of travel (driving, flying, cruise ship, etc.), and any activities you did on your trip:
(Example:  Cancun Mexico, Vacation, Flew from Atlanta, went SCUBA diving)

Do you wear an Apple Watch, Fitbit, Garmin Watch or other fitness tracker on a regular basis?  If YES, please provide the type of fitness tracker you wear (the insurance company will ask to review the data to see if you have been active since the accident to argue against your pain and suffering claim)

Do you belong to any church, fraternity/sorority, social club, union, lodge, committee or association?  If yes, please describe all below:

Have you ever served in the United States Military?  If so, please provide the branch, date(s) of service, and highest rank achieved:

EDUCATION HISTORY:

Did you attend high school?  Provide the name of your school and the year(s) you attended:

Did you attend college or technical school?  Provide the name of your school and the year(s) you attended, and what your major was if you graduated:

Did you attend graduate school??  Provide the name of your school and the year(s) you attended, and what your major was if you graduated:

Do you currently hold any specialized degrees, licenses, certifications, or other training:

CRIMINAL & DRIVING HISTORY

Have you ever been arrested for any reason (even if the case was later dismissed)?  We are required to disclose all arrests to the insurance company or your case may be dismissed by the court. 
Please provide the approximate year, the charge(s), the county, and the sentence for each and every arrest [Example:  2020, Possession of Marijuana, Fulton County, 12 Months Probation]

Have you ever received any traffic tickets in the last 5 years?  If yes, please provide the traffic offense, the court, the approximate date of the offense, and the sentence.
[Example:  Speeding (25 MPH over speed limit), City of Atlanta Traffic Court, 2023, Paid Fine]

MEDICAL HISTORY:

Did you consume any alcohol or drugs in the 24 hour period before this accident?  If yes, please list what substance(s) you consumed and the amount(s):

Are you required to wear glasses or contacts when you drive?  If YES, were you wearing them on the date of this accident? 

Were you taking any prescription medication on the date of this crash?  If yes, please provide the name(s) of your prescription medication(s) and the doctor who prescribed it for you.
(Example: Lipitor – Prescribed by Dr. John Smith)

Have you ever had surgery for ANY reason before or after this accident (other than for childbirth)?  If so, please provide: (1) The type of surgery; (2) The doctor or medical facility who performed the surgery; and (3) The approximate date of the surgery.
(Example:  Appendix Removed, Piedmont Atlanta Hospital, 2015)

Please list ALL doctors or medical practices you have seen in the last ten (10) years (OTHER than those you treated with for this accident, we have those names already) and the reason you see that doctor. 

Please include your primary doctor, dentist, family doctors, therapists, OBGYN, and other specialists.  (Example:  Dr. John Smith, Primary Care;  Dr. Robert Jones, Cardiologist)

Please list the name and address of all pharmacies you have used in the last five (5) years.  The insurance company will verify all Rx drugs you received in the timeframe around this accident.
Example:  (CVS on Cheshire Bridge Road;  Kroger on North Decatur Road)

If you had health insurance, Obamacare, Medicare, Medicaid, Peach State Health Plan, CHAMPUS, Tricare, or any other health insurance coverage on the date of this accident – Please upload a FRONT AND BACK photo of your insurance card.  FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN A LONG DELAY IN SETTLING YOUR CASE AND/OR THE CANCELLATION OF YOUR INSURANCE BY YOUR PROVIDER. 

Has your health insurance company contacted you about this accident?  If YES, please provide the phone number and case number for their claim (they may have sent you some paperwork to fill out, you may call our office if you received this paperwork to discuss)

Are you currently employed?  If YES, please provide the name and address of your employer, your job title, your pay rate or salary, and the year(s) of employment.
(Example:  Home Depot on Piedmont Avenue, Cashier, $15.00/hour, 2015 – Present Day)

Have you ever been divorced before?  If YES, provide the county/state where your divorce case was filed, and the approximate year:

Have you ever filed a Workers Compensation claim for an injury on the job?  If YES, please provide the name of the employer, the type of injury, the name(s) of all doctors you saw for the injury, the year of the injury, and the settlement information below. 
Example:  Home Depot, back injury from lifting boxes, went to Concentra Urgent Care, 2015, settled for $2500.00.

On the date and time of this accident, where were you coming from, and what was your intended destination (Example:  Leaving my job at Home Depot, going back home):

Are there any witnesses who can testify about the change in your quality of life due to these injuries from this accident?  If YES, please provide their full name, address, phone, and email: