Please provide a summary of the incident causing you personal injury in as much detail as possible.
Please provide the store location and address for where the incident occurred. In this section, please also indicate whether you have visited this store location before.
Please provide a summary of the conditions of the premises immediately before the incident to the best of your recollection.
Please provide as much information as possible on any potential bystanders or witnesses who observed the incident and/or the conditions of the store immediately prior to the injuy.
Please describe in detail the injuries sustained as a result of the fall.
Please provide a complete list of medical treatment providers who attended to your injuries, including hospitals, doctors, pharmacies, EMS, Physical Therapists, etc.
Please describe your recovery from the injuries, including any complications, present condition, residuals, and expected timeframe for recovery. Please indicate your pain level from 1-10 for each stage of your recovery, including where it currently is on a daily basis.
Please describe in detail any restriction on movement and/or activities resulting from your injury, including loss of sleep, daily routines, etc. Provide details on any loss of independence and/or reliance on others for everyday tasks.
Please describe in as much detail as possible the manner in which your life has changed since the incident. For example, list any hobbies or activities that you are no longer able to participate in due to the nature of your injuries.
Please provide the latest treatment plan, including the doctor/medical provider responsible for creating the recovery plan. Please indicate whether any doctor believes any particular injury will be permanent.
Please list all insurance carriers that contribute to your medical payments, whether that be a private company or Medicare/Medicaid.
