LLMI Smart Interview

1

Welcome to the LLMI Smart Interview

This interview should take about 10–15 minutes. If you’re not sure about something, you may enter Unknown and continue.

Please have any helpful details nearby, such as names, dates, phone numbers, and documents. Here are some common documents you may need for this intake process:

Incident Report
Vehicle Information
Driver's License Number
Medical Information
Witness Information
Insurance Information

2

Contact Person NameWho should we contact if we have questions about this matter?

First Name

Middle Name

Last Name

Suffix

3

Is the contact person also the injured person?

Yes

No

4

Contact Person PhoneBest phone number to reach the contact person.

5

Contact Person EmailBest email address for the contact person.

Example: name@example.com

6

Contact Person AddressMailing address for the contact person.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Injured Person NamePlease enter the injured person’s full name.

First Name

Middle Name

Last Name

Suffix

8

Injured Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

GenderInjured person

10

Date of BirthInjured person’s date of birth.

Example: 01/15/1985

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Last 4 of SSNIf needed, enter only the last 4 digits of the Social Security number.

Example: 1234

12

Driver LicenseInjured person

Example: D123-456-78-901-0

13

Marital Status

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Spouse NameName of Injured person's spouse

First Name

Last Name

15

Spouse Phone No.

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Injured Personal IdentificationInjured person

Date of Birth

SSN

Driver License #

Gender

Work/School Status

Marital Status

Spouse Name

Spouse Phone

17

Name of GuardianFull name of guardian

18

Type of IncidentChoose the option that best fits what happened.

Examples: auto accident, slip and fall, dog bite.

19

Other Case Type

Other type of case

20

Injured roleWhat role did the injured party have?

21

Were you the Driver or Passenger of a vehicle?At the time of the incident if you are operating a vehicle or a passenger in a vehicle please select "Yes".

YESNO

22

Vehicle InformationProvide information of the owner of the vehicle you were driving or a passenger of.

Year

Make and Model

Insurance Co.

VIN#

Vehicle Ins. Phone

Ins. Policy #

Owner Name

Owner Phone#

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Case MatterProvide an official case name for this matter

Provide an official case name for this matter

24

Employed?Is the injured person employed?

YESNO

25

EmployerList employment information

Name

Address

Position

Phone

Wage

How long employed?

26

Work Conditions

Name of Forman

Phone

Carrier's Name & Address

Date employer was notified of injury

Notice given to (specific person)

Date lost time began

Description of accident or cause of injury

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General Injury LocationsClick all that apply

Head area

Face area

Body area

Other Extremities

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Head InjuriesSelect all head injuries that apply

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Face InjuriesSelect all face injuries that apply

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Body InjuriesSelect all body injuries that apply

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SymptomsSelect all symptoms that apply

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Other Extremities InjuriesArms, Legs, Hands & Feet (Select all injuries that apply)

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Did you miss work/school?

Yes

No

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Amount of time missed?How much time missed from work or school?

35

Prior Accidents/ClaimsHave you ever had prior accidents of any kind or made a claim?

YESNO

36

Accidents/ClaimsList date and type of all prior accidents or claims you have had.

Claim #1

Claim #2

Claim #3

Claim #4

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Do you have any health conditions?Let us know if there are any health conditions we should be aware of.

Yes

No

38

Prior DisabilitiesDo you have or have you ever had any disabilities?

YESNONE

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Health Condition DetailsList any relevant health conditions.

Health condition details

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Health Care ProvidersProvide the name, address and phone# of each hospitals, doctors and other health care providers.

Health Care # 1

Health Care # 2

Health Care # 3

Health Care # 4

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Incident LocationWhere did the incident happen?

Provide as much information regarding the location of the incident

42

Was there an incident report made?Such as a Police report, Medical report, Other

YESNO

43

Reporting AgencyWhat agency made a report of incident? (i.e. Police, Sheriff, EMT, Other)

Agency Name

Report#

Incident Location

Date of Incident

Time of Incident

Witnesses?

Name of officer taking report?

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Witness ListProvide name, address and phone# of each witness.

Witness # 1

Witness # 2

Witness # 3

Witness # 4

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ExplanationPlease explain your activity leading up to the incident.

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DependantsDo you have dependants other than your spouse?

YESNO

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Dependants InformationDependant(s) name, age and relationship. Note: Click the plus button to the right to add an additional dependent.

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Do you own a vehicle?* This field is required.

YESNO

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Vehicle OwnershipVehicle description

Year

Make and Model

Insurance Co

Insurance Phone

Insurance Policy #

Do you have a second vehicle?

51

2nd Vehicle2nd Vehicle description

2nd Vehicle Year

2nd Vehicle Make and Model

2nd Vehicle Insurance Co

2nd Vehicle Ins Phone

2nd Vehicle Ins Policy #

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Transport Vehicle InfoTransport vehicle description

Transportation Vehicle Year

Transportation Vehicle Make and Model

Transportation Vehicle Owner

Transportation Vehicle Insurance Company

Transportation Vehicle Owner Phone

Transportation Vehicle Policy #

Transportation Vehicle Driver Name

Transportation Vehicle Driver Phone

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17. InsuranceCheck all insurance coverage that you have.

None

Homeowner Insurance

Auto Insurance

Health Insurance

Life Insurance

54

Auto InsuranceAuto insurance information

Auto Ins Co

Auto Ins Policy #r

Auto Ins Phone

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Homeowner InsuranceHomeowner insurance information

Homeowner Ins Co

Homeowner Ins Policy #

Homeowner Ins Phone

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Health InsuranceHealth insurance information

Health Ins Co

Health Ins Policy #

Health Ins Phone

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Life InsuranceLife insurance information

Life Ins Co

Health Ins Policy #

Health Ins Phone

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Other injured family or friendsWere there other family or friends injured in your group from this incident?

YESNO

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List other injured partiesProvide name and age of other injured family /friends in your party

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19. Re:* This field is required.Please provide a reference name for your case. (example: John Doe vs. ACME, Inc.)

Example: John Doe vs. ACME, Inc.

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DefendantDefendant's information

Name

Address

Phone

Email

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Other Defendant Info

63

Record Voice NarrativeIn your own words describe the order of events leading up to the incident

64

Tell Us What HappenedExample: I was stopped at a red light when another vehicle struck me from behind.

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Upload Case FilesUpload photos or documents regarding this case.

Drag and drop files here

Select files to upload

Max. file size: 10.0MB

Upload Documents

Photos, records, and other helpful documents.

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22. Other comments

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Submission of this form authorizes Larry L. Mabson Investigations to process, manage and investigate this matter as needed on behalf of {contactPerson[1]}, injured client.

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Date of InterviewWhen did this interview take place?

Date

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Do You Have an Attorney?

Yes, I have an attorney

No, I no longer have an attorney

No, never had an attorney for this case.

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Would You Like an Attorney Referral?Would you like to have an attorney referral?

Yes

No

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How far will you travel to an attorney?

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Attorney InformationAttorney contact Information

Attorney Name

Attorney Phone#

Attorney Address

Attorney City

Attorney State

Attorney Zip

Attorney Email

Firm Name

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Client Retainer Agreement SignatureFull Name

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SignatureClient signature

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Who Completed This Form?

Client

Parent/Guardian of injured party

Mabson Investigations o/b/o of client

Other

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Enter the message as it's shown* This field is required.