Full name, address, telephone number, fax number, email;
Date of birth;
When did the accident or incident occur (date and time);
Where did the accident happen;
Describe what happened and what caused the accident;
Describe your injuries;
When and how long were you treated in a hospital or physicians;
What are your medical expenses, including those which have been paid for and those which have not (and what medical expenses do you anticipate having in the future);
Have you lost time from work as a result of your accident? How much in lost wages have you incurred so far? How much in lost wages will you incur in the future?
Describe your disabilities and what you cant do now that you could do before the accident?
Were you ever treated for this type of injury or problem before this accident?