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William C. Crantford
Jerry A. Meehan, Jr.
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Personal Injury
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Motorcycle Injuries
Truck Accidents
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Practice Areas
Personal Injury
Car Wrecks
Motorcycle Injuries
Truck Accidents
Bicycle Accidents
Slip and Fall Injuries
Construction Injuries
Criminal Defense
Workers Compensaton
Real Estate Law
Estate Law
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Practice Areas
Personal Injury
Car Wrecks
Motorcycle Injuries
Truck Accidents
Criminal Defense
Real Estate Law
Estate Law
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FREE CASE REVIEW
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(843) 832-1120
Personal Injury Client Intake Form
Client Information
Full Name
(Required)
Date of Birth
DD dash MM dash YYYY
Preferred Contact
Text
Call
Email
Email
Phone
Alt. Phone
Street Address
City
State
ZIP
Incident Overview
Tell us what happened and when.
Incident Type
Motor Vehicle Collision
Slip/Trip & Fall
Dog Bite
Workplace Injury
Product Liability
Other
Date
(Required)
DD dash MM dash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Location (address / intersection)
(Required)
Country
Brief Description
(Required)
Police Report #
Officer/Agency
At‑Fault Party & Insurance
At-Fault Party Name
Insurer
Policy #
Claim #
Adjuster Name
Adjuster Email
Adjuster Phone
Injuries & Treatment
Injuries (body parts, symptoms)
EMS/ Ambulance?
No
Yes
ER Visit?
No
Yes
ER Facility
Treating Providers (names)
Ongoing Treatment?
No
Yes
Health Insurance
Auto MedPay Coverage
Client Vehicle (if motor vehicle case)
Vehicle (year/make/model)
Management Company
Your Auto Insurer
Your Claim # (if filed)
Employment & Damages
Currently Employed?
Yes
No
Employer Name
Job Title
Missed Work (days)
Wage Rate ($/hr or salary)
Other Damages (mileage, childcare, etc.)
Witnesses
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Name
Phone
Email
Prior Injuries & Claims
Prior Similar Injuries?
No
Yes
Details
Prior Claims/Lawsuits?
No
Yes
Details
Evidence & Documents
Upload is optional; file names are listed locally only.
Driver's License (front & back)
Drop files here or
Select files
Max. file size: 128 MB.
Police / Accident Report
Drop files here or
Select files
Max. file size: 128 MB.
Insurance Policy / Declarations Page
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Select files
Max. file size: 128 MB.
Other Evidence / Documents
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Select files
Max. file size: 128 MB.
Acknowledgments
Notice:
Submitting this form does not create an attorney‑client relationship. Representation begins only after a signed agreement by the firm.
Medical Records Authorization:
By checking below, you authorize the firm to obtain medical/billing records related to this incident for evaluation purposes.
Consent (required to submit)
(Required)
I acknowledge and authorize retrieval of relevant medical records.
Consent (required to submit)
(Required)
I certify the information is accurate and complete to the best of my knowledge.
Typed Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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