Discovery Web Form First NameLast NameEmail Please list your full legal name and any previous full legal names (including maiden names or prior married names) and the years you were known by those names.Are you currently married? Yes No Full legal name of spouseCity and state of marriageDate of marriage Have you had any prior marriages? Yes No List information of prior marriage(s)If you have more than one prior spouse, please use the plus (+) sign on the right to add the information for more prior marriagesFull legal name of prior spouseDate and place of marriage (city and state)Date and place of marriage termination (county and state) Add RemoveHave you have any children? Only include biological children, adopted children, or children for whom you are a legal guardian. Yes No List information of child(ren)If you have more than one child, please use the plus (+) sign on the right to add the information for each childFull legal name of childDate of birth Add RemoveAre you older than 65 years old? Yes No Have you received social security benefits for more than 24 months? Yes No Have you ever been diagnosed with end stage renal disease? Yes No Have you ever been diagnosed with Lou Gehrig’s disease? Yes No Please provide your current address and all addresses where you have resided for the past ten (10) years:If you have multiple addresses to list, please use the plus (+) sign on the right to add the information for each childAddressDates when you lived there (Years of residency is sufficient)Identify all people you resided with Add RemovePlease provide your current occupation, job title, and employerPlease provide your complete educational background beginning with high school and include professional certifications.If you have multiple educational institutions to list, please use the plus (+) sign on the right to add the information for each one.Name of schoolDates attendedDegree received Add RemoveList any and all (moving and non-moving) traffic violations/tickets/citations in the past ten (10) years, including DUIs and DWIs:If you have multiple offenses to list, please use the plus (+) sign on the right to add the information for each one.Nature of offenseDate of offenseLocation of offense (County and State)Outcome or disposition of offense Add RemoveHave you ever been involved in any other legal action of any kind? (this includes bankruptcy, divorce, child custody, landlord/tenant, probate, etc.) Yes No Information on legal actionsIf you have been involved multiple legal actions, please use the plus (+) sign on the right to add the information for each one.Whether you were a Plaintiff or DefendantCounty and State of legal actionOutcome of legal action Add RemoveDid you possess a cell phone at the time of the incident? Yes No Cell Phone InformationPlease provide: i. Cell phone number at the time of the incident ii. Service Provider (Verizon, AT&T, etc.) iii. Name and address of account holder Other than anyone listed on the police report, identify any eyewitnesses to this event or those who have knowledge of the facts or circumstances concerning the incident/accident. Please provide names, addresses, and phone numbers.Have you or anyone known to you given a statement (written or recorded) regarding this event to law enforcement, insurance companies, other attorneys, etc. Please identify each statement taken from any person with knowledge relevant to this incident.Please list all accidents or incidents where you received personal injuries prior to this incident (Including car wrecks, falls, sports injuries, etc.)If you have been involved multiple accidents, please use the plus (+) sign on the right to add the information for each one.Describe injuriesDate of injuryTreating physicians/hospitalsType of treatment (chiropractic care, physical therapy, steroid injections, surgery, etc.) Add RemovePlease list all accidents or incidents where you received personal injuries after this incident (Including car wrecks, falls, sports injuries, etc.)If you have been involved multiple accidents, please use the plus (+) sign on the right to add the information for each one.Describe injuriesDate of injuryTreating physicians/hospitalsType of treatment (chiropractic care, physical therapy, steroid injections, surgery, etc.) Add RemoveIdentify any churches, social clubs, volunteer groups, local civic leagues or association, or any other social groups in which you have been a member or participated in the last ten (10) years:Have you taken any prescription medication within ten (10) years preceding the incident? Yes No Please list any any prescription medication you have taken within ten (10) years preceding the incidentIf you have been involved multiple accidents, please use the plus (+) sign on the right to add the information for each one.Name of medicationName and address of prescribing doctorName of pharmacy or drugstore which filled prescription Add RemoveHave you ever applied for disability benefits? Yes No Please list any any disability benefits you have ever applied for.If you have applied for multiple disability benefits, please use the plus (+) sign on the right to add the information for each one.Year filedWhether granted or deniedIf denied, whether you appealed or notResult of the appealState the physical or medical condition you based the application on. Add RemoveHave you ever made a claim for workers’ compensation? Yes No Please list any any workers' compensation claim you have ever made.If you have made multiple workers' claims, please use the plus (+) sign on the right to add the information for each one.Name of your employer at the time of incidentState in which this was filedYear the action was filedType in incident and injuryOutcome of the claim Add RemoveState where the incident/accident took place, including the date, time, and weather and traffic conditions at the location of the incident.At the time of the incident, where you listening to the radio, eating, using a cellphone, or conversing with any passengers in your vehicle? Yes No Please explain:Have you had any communications with the defendant or an agent of the defendant (insurance company, attorney, etc.) at the time of the incident/accident or at any time following the incident/accident? This includes a phone call that could have been recorded. Yes No Please explain:Did you consume any prescription medication, alcohol or recreational drugs within a 24-hour period immediately prior to the incident in issue? Yes No If so, please include:i. Medication or substance consumed ii. Reason why iii. Amount consumedDo you wear glasses or other corrective lenses either daily or for certain activities? Yes No If so, please provide:i. Name and addresses of each hospital ii. Date of treatment iii. Reason for or nature of treatmentHave you been hospitalized (admitted to the hospital) at any time in the ten years prior the incident/accident? Yes No If so, please provide:i. Name and address of eye doctor ii. Date of last eye examination iii. Whether you were wearing the contacts or glasses at the time of the incident/accident.Have you been hospitalized (admitted to the hospital) at any time since the incident/accident? Yes No If so, please provide:i. Name and address of eye doctor ii. Date of last eye examination iii. Whether you were wearing the contacts or glasses at the time of the incident/accident.
