Facebook

LinkedIn

Search
 

Personal Injury Form

MEXLAW > Personal Injury Form

PERSONAL INJURY QUESTIONNAIRE[1][2]

 

This questionnaire is designed to provide sufficient information to allow us to consider the merits of your claim and to advise you on what procedures to take and the probability of success.  Do not send any documents at this time.

 

The questionnaire should be completed by the victim of the incident. If the victim is a minor (under 18 years of age) the questionnaire should be completed by a legal representative, usually the parent, who will be filing the claim on behalf of the minor.

PERSONAL DETAILS

Personal title*
First Name*:
Family Name*:
Second Name:
Street:
City*:
State/Prov*:
Country*:
Postal Code*:
Relationship with client :
Telephone No*:
Email*:
Minor’s Full Name:
Minor’s DOB:
INCIDENT DETAILS (Select Only the Appropriate SECTION):

Section-1 Vacation Related Incident

(Hotels, Beach Club, Restaurants Etc.)

Vacation Package Provider:
City*:
State*:
Was this an all-inclusive package?*
Did you purchase travel insurance?*
Booking Number/Reference:
Cost*:
Check in*:
Check out*:
Did you sign a disclaimer or a release?
Name of Hotel*:
City*:

Section-2 Excursions/Vehicle Rental Incidents/Other

(SCUBA, BICYLE, HORSBACK, ETC.)

Who did you purchase the excursion, activity or rent the vehicle from? Please provide details of this contract:
Did you sign a disclaimer or a release?*

Incident Details for Sections 1 & 2

Date of the incident*:
Time*:
Location of Incident*3:
Please provide details of the Incident

Section-3 Medical Malpractice

Name of Clinic/Hospital/Dr./Dentist*
City*:
State*:
Was this a treatment or surgery?*
What was included? (travel, accommodation, surgery, medicine, etc)
Name of treating Doctor
Describe the Treatment/Surgery
Do you have a medical report prior to the treatment or surgery?*
Did the Doctor explain the medical procedure to you?*
Did you sign any consent for the medical procedure?*
Do you have prescription information of the medications you take?*
Did you request your clinic history?*
Did you take photographs of the injury?*
Did you sign a disclaimer or a release?*
Cost*:
*Required fields

Notifications

Did you notify anyone about the incident?*
If yes, provide details
What was the outcome? Were you offered compensation?
Did you complete an accident report?*
Did police or first responders attend?*

Witnesses

Witnesses 1
Name:
Address:
Telephone No.:
email:
Relationship:
Witnesses 2
Name:
Address:
Telephone No.:
email:
Relationship:
*Required fields

Provide Details Of Injuries Following the Incident
4 Hospitalization

Did you consult a Doctor or were you hospitalized in Mexico as a result of the incident?
If yes, Name of Hospital/Doctor:
Hospital Reference Number (if known):
City:
State:
Dates of consultations:
Were you reimbursed for any of these expenses?
Brief details of any medical treatment

Subsequent Hospitalization or Treatment When You Returned Home

Name of Hospital/Doctor:
Address:
File reference number (if known):
Date(s):
Were you reimbursed for any of these expenses?
Brief Details of Treatments
Please describe how the injuries sustained affect your life (include as many details as possible) and give details of the nature and severity of any pain suffered
*Required fields

DAMAGES

Absence from Work

Were you absent from work due to the incident? If so, please confirm the dates you were absent at the end of this form*
Name of Employer*:
Address of Employer
Bimonthly Net Salary*:
Do you have any dependents?*

Gvt. Benefits

Were you receiving any state benefits (other than child benefit)?
If yes, which benefits?
Dates Absent:

Provide details of any losses and expenses incurred

Loss of income

Supporting Documents Available?
Appx Value (USD)
Comments

Supporting Documents Available?
Appx Value (USD)
Comments
Travel expenses (to and from treatment etc)

Supporting Documents Available?
Appx Value (USD)
Comments
Medical Expenses

Supporting Documents Available?
Appx Value (USD)
Comments
*Required fields

Please list any other expenses directly related to the incident

Item 1
Appx Value (USD)

Supporting Documents Available?
Comments



Item 2
Appx Value (USD)

Supporting Documents Available?
Comments

Physical Limitations

Did you suffer any temporary physical limitation because of the incident?*

Supporting Documents Available?*
Comments
Did you suffer any permanent physical limitation because of the incident?*

Supporting Documents Available?*
Comments

Please provide any additional information which will assist us

I declare that the statements and facts related above are true.*
Name*:
Date*:
*Required fields

[1] Once completed, this information will be considered confidential and will only be made available on a need to know basis.

[2] If you require more space to reply, please use the space provided at the end of this form.

[3] Be as specific as possible, street, city, state.

[4] If you sustained a visible injury, such as bruising, swelling, burn or scarring, it would assist us if you photograph, while the injury remains visible. We recommend that you keep a journal of the treatments received and take regular photographs to show the progress of the symptoms and recovery.