Client Intake | Aghabegian Law Group

Getting started

About you

The collision

Injuries & medical

Vehicles & insurance

History

Review & Submit

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Aghabegian Law Group

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Questions? Call us · (818) 350-HURT (350-4878)

Confidential client intake

What happened?

Choose the option that best describes what happened. We'll tailor the questions to your situation.

Questions? Call us · (818) 350-HURT (350-4878)

Confidential client intake

Let's talk first

Leave your name and number and our team will reach out. There's no long form to fill out.

Your name

Phone number

Anything you'd like us to know? (optional)

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Questions? Call us · (818) 350-HURT (350-4878)

Confidential client intake

Let's get your case started.

This form takes about 15–20 minutes to complete. You can upload photos of your documents instead of typing everything. We’ll pull out the key details for you.

Everything you share is confidential and protected. Please answer as carefully and completely as you can so we have what we need to handle your case properly.

Your progress saves automatically. Stop and return anytime.

Before you begin

Have these ready if available.

Your driver's license
Your insurance card, or your full coverage page (declarations page)
Your vehicle registration
The other driver's license, insurance, or registration (if you have any)
Police report, or the card the officers gave you at the scene
Photos or videos of the damage, injuries, or scene
Any medical bills or paperwork you have

Questions? Call us · (818) 350-HURT (350-4878)

Upload Your Documents

Upload any of the documents below and we'll automatically fill in parts of the form for you. This step is optional. You can skip it and fill everything in manually.

You can type everything in yourself.

We will ask you for each of these details on the next few steps. If you change your mind, choose Show upload zones above.

Files you already added are still attached. Choose Show upload zones if you want to remove them.

Your Driver's License A photo or PDF file

Your Auto Insurance Card A photo or PDF file

Your Vehicle Registration A photo or PDF file

Other Driver's Documents (if available)

Other Driver's License A photo or PDF file

Other Driver's Insurance Card A photo or PDF file

Other Driver's Vehicle Registration A photo or PDF file

Getting Started

Who is completing this form?

Client Someone else

Name of person completing form

When is the best time to reach you?

Morning (before noon) Afternoon (12 pm – 5 pm) Evening (after 5 pm) Anytime

How did you hear about us?

At the time of the collision, were you the...

Does our office also represent the driver?

Yes

Driver's full name

Was a rideshare or food delivery vehicle involved? (Uber, Lyft, DoorDash, Grubhub, etc.)

Yes

I don't know / don't remember

How was rideshare/food delivery involved?

Which platform?

What was the app status at the time of the collision?

Your Information

Full Legal Name (First, Middle, Last)

Date of Birth

Driver's License Number If you uploaded your license we may have filled this in. Please check it.

Age

What is your marital status?

Spouse/Partner's Full Legal Name (first, middle, last)

What is your employment status?

Occupation

Employer/Company Name

Contact & Address

Cell Phone

Home Phone

Address

Street Address

City

State

Zip

Emergency Contact

In case of an emergency, who should we contact?

Name

Phone

Relationship

Collision Date & Time

When did the collision occur?

Day of the week

What time did the collision occur?

Vehicles & Impact

How many vehicles were involved in the collision (including yours, if applicable)?

How many people were in your vehicle including you?

Any car seats?

Yes

Were you wearing a seatbelt?

Yes

Type of impact

Select the best description of the initial impact. If none apply, select "Other."

Describe other impact type

Point of impact to your vehicle

Describe

Trip Context

Where was your trip starting from?

Location (include street and city)

Name and location (include street and city)

Business name and location (include street and city)

Describe where your trip began (include street and city)

Where were you headed?

Location (include street and city)

Name and location (include street and city)

Business name and location (include street and city)

Describe your destination (include street and city)

Collision Location

Where did the crash occur?

At an intersection

On a street but not at the intersection

On a freeway or highway

In a parking lot or on private property

Other

Which street were you on?

Which street was the other driver on? If the other driver was on the same street as you, enter the same street again.

Nearest cross street

Traffic control device

Describe the traffic control

Freeway (e.g. I-5, US-101, 210)

Direction

Nearest exit

Name and address of the business or property

Describe the location and provide address

City

Your Movement

What direction were you traveling?

Which lane were you in?

What was your approximate speed?

What was your vehicle doing immediately before the collision?

What were you doing immediately before the collision?

Describe

Where were you located immediately before the collision?

Describe

Were you wearing a helmet at the time of the collision?

Yes No

What kind of helmet?

e.g., full-face motorcycle helmet, road bike helmet, mountain bike helmet. Include the manufacturer or brand if you know it.

Do you have photos of the helmet?

Especially helpful if there's any visible damage.

Yes No

You can attach more than one. Photos showing damage are especially helpful.

Photos of the helmet You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Other Driver's Movement

What direction was the other vehicle traveling?

Which lane was the other vehicle in?

What was the other vehicle's approximate speed?

What was the other vehicle doing immediately before the collision?

Describe the Collision

Please describe the collision in as much detail as you can, including what you saw, heard, and felt. Include the events leading up to, during, and immediately after the collision.

Roadway & Weather Conditions

Traffic conditions

Weather

Lighting

Road surface

Were there any unusual roadway conditions?

911 & Police

Did anyone call 911?

Yes No I don't know / don't remember

Who called 911?

Why not?

Did police respond to the scene?

Yes No I don't know / don't remember

Which law enforcement agency?

Was a police report prepared?

Yes No I don't know / don't remember

Did you file a police report on your own?

Yes No

Report Number

Was anyone cited?

Yes No I don't know / don't remember

Who was cited?

Citation #

Ambulance

Did the ambulance arrive at the scene?

Yes No I don't know / don't remember

Were you transported by ambulance?

Yes No

Name of ambulance company that transported you

Name of hospital you were transported to

Statements & Fault

Did you speak with anyone while at the scene?

Yes No I don't know / don't remember

Who did you speak to?

Did anyone admit fault at the scene?

Yes No

Who admitted fault?

What was said?

Photos & Cameras

Did you or anyone take photos or videos?

Yes No

Who took them?

Photos or videos from the scene You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Were there any dashcams or surveillance cameras that may have recorded the collision?

Yes No I don't know / don't remember

Were there any traffic or red-light cameras?

Yes No I don't know / don't remember

Describe the type and location of cameras

Dashcam or camera video you already have You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Witnesses

Were there any witnesses?

Yes No I don't know / don't remember

How many witnesses?

Witness 1

Witness Name Witness Phone

Witness 2

Witness Name Witness Phone

Witness 3

Witness Name Witness Phone

Witness 4

Witness Name Witness Phone

Tell us about the other witnesses

Please include a name and a phone number for each one, one per line.

Vehicle Basics

Year

Make

Model

Color

License Plate

Are you the registered owner?

Yes No

Registered owner's name

Registered owner's address

Is the vehicle leased or financed?

Yes No

Leasing/finance company name

Vehicle Damage / Towing / Rental

Do you have photos or videos of the damage?

Yes No

Photos or videos of the damage You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Did the airbags deploy?

Yes No

Was the vehicle towed from the scene?

Yes No

Is the vehicle currently driveable?

Yes No

Do you require a rental?

Yes No

Do you have rental coverage?

Yes No I don't know / don't remember

Where is the vehicle currently?

Location

Body shop name Phone

Tow yard name Phone

Your Auto Insurance

Does the driver of the vehicle you were in have car insurance?

Yes No I don't know / don't remember

Do you or anyone in your household have car insurance?

Yes No I don't know / don't remember

Driver's/Your Insurance Policy

Insurance Company

Policy Number

Have you reported the collision to this insurance company?

Yes No

Do you have a claim number?

Yes No I don't know / don't remember

Claim number

Have you given a recorded or written statement to this insurance company?

For example, a phone interview, recorded call, written summary, or signed statement.

Yes No

Registered Owner's Insurance (if different)

Does the registered owner have separate car insurance?

Yes No I don't know / don't remember

Name of registered owner's insurance company

Policy number (registered owner)

Your Own Car Insurance (if separate from driver's)

Do you have your own car insurance policy (separate from the driver's)?

Yes No

Your insurance company

Your policy number

Coverage Details

Do you have Uninsured / Underinsured Motorist (UM / UIM) coverage?

This is coverage on your own policy that may apply if the other driver had no insurance or not enough insurance.

Yes No I don't know / don't remember

What are your UM/UIM limits? (If you don't know write "unknown")

Do you have Medical Payments (Med-Pay) coverage?

This is optional medical-payment coverage on your auto policy.

Yes No I don't know / don't remember

How much is your Med-Pay coverage? (If you don't know write "unknown")

Other Driver Information

Do you have any information about the other driver?

Yes No

No problem. We'll obtain this information.

Other Driver's Personal Information

Full Name (First, Middle, Last)

Street Address

City

State

Zip

Phone

Driver's License #

Was the other driver driving for work or business?

Yes No I don't know / don't remember

Employer/business name

Other Driver's Vehicle

No problem. We'll obtain this information.

Year

Make

Model

Color

License Plate

Was the other driver in a commercial vehicle?

Yes No I don't know / don't remember

Was the other driver also the registered owner?

Yes No I don't know / don't remember

Registered owner's name

Registered owner's address

Do you have photos or videos of their vehicle damage?

Yes No I don't know / don't remember

Photos or videos of the other vehicle You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Did the other vehicle's airbags deploy?

Yes No I don't know / don't remember

Was the other vehicle towed from the scene?

Yes No I don't know / don't remember

Other Driver's Insurance

You can skip this step. We'll obtain insurance information for the other driver.

Other driver's insurance company

Policy Number

Has the collision been reported to the other driver's insurance?

Yes No

Do you have a claim number?

Yes No I don't know / don't remember

Claim number

What are the policy's liability limits? (if unknown, write 'unknown')

Have you given a recorded or written statement to the other driver's insurance company?

For example, a phone interview, recorded call, written summary, or signed statement.

Yes No

Does the registered owner of the other vehicle have separate insurance?

Yes No I don't know / don't remember

Name of registered owner's insurance company

Policy number

Additional Drivers

You indicated that more than two vehicles were involved. Please provide any information you have about the other driver(s). If you don't have this information, no problem. We'll obtain it.

After the Collision

Where did you go after the collision?

If you were transported to a hospital from the scene, select where you went after leaving the hospital.

Where?

Injuries & Symptoms

Describe your injuries and symptoms

Mark where it hurts

Draw on the areas of your body that hurt. Pick a color for how bad the pain is. This is optional.

Mild Moderate Severe

Marked areas

Nothing marked yet.

When did your symptoms begin?

Medical Care So Far

Have you received medical care?

Yes No

Select all medical treatment you have received so far

Hospital Urgent Care Doctor Chiropractor / physical therapy Diagnostics (e.g., MRI, CT scan, X-ray, EKG)

Hospital

Hospital name

Location

First visit

Urgent Care

Name

Location

First visit

Doctor

Name

Location

First visit

Chiropractor / Physical Therapy

Name

Location

First visit

Medical records, bills and paperwork Photos or PDF files. You can add more than one.

Diagnostics

Name

Location

First visit

Health Insurance

Do you have health insurance?

Yes No

Health insurance company name

Do you have Medi-Cal?

Yes No

Do you have Medicare?

Yes No

Is your health insurance provided by your employer?

Yes No

Did your health insurance pay for any medical bills related to this collision?

Yes No I don't know / don't remember

Which bills?

Primary Care Physician / Family Doctor

In the past 10 years, have you had a primary care physician (PCP) or family doctor?

Even if you didn't see them often, or no longer see them.

Yes No

Doctor's Name

Office location (city and clinic name, if known)

How long have you been seeing this doctor?

Most recent visit

Work & Wages

Have you lost any wages because of this collision?

Yes No

Were you injured on the job?

Yes No

Have you filed a workers' compensation claim?

Yes No

Prior Similar Complaints

These next questions ask about any similar injuries or personal-injury claims from before this collision. We're not looking for reasons to doubt you. We're getting ahead of the arguments defense attorneys will make about pre-existing conditions. The more we know early, the better we can protect your case.

Before this collision, did you have similar symptoms or injuries involving the same body parts?

Yes No

Approximate answers are okay. If you do not remember exact dates or provider information, give your best estimate.

Prior Complaint 1

Body part involved

When did your symptoms begin?

Was this from another accident?

Yes No

When did that accident happen?

Whatever you remember works: full date, just the month and year, or just the year.

Did you receive medical care?

Yes No

List any doctors, clinics, or facilities you saw for this condition.

At the time of this collision, were you still having symptoms or getting treatment for this condition?

Yes No

Add another prior complaint?

Yes No

Prior Complaint 2

Body part involved

When did symptoms begin?

Was this from another accident?

Yes No

When did that accident happen?

Whatever you remember works: full date, just the month and year, or just the year.

Did you receive medical care?

Yes No

List any doctors, clinics, or facilities you saw for this condition.

At the time of this collision, were you still having symptoms or getting treatment for this condition?

Yes No

Add another prior complaint?

Yes No

Prior Complaint 3

Body part involved

When did symptoms begin?

Was this from another accident?

Yes No

When did that accident happen?

Whatever you remember works: full date, just the month and year, or just the year.

Did you receive medical care?

Yes No

List any doctors, clinics, or facilities you saw for this condition.

At the time of this collision, were you still having symptoms or getting treatment for this condition?

Yes No

Prior Claims/Lawsuits

Have you ever made a personal injury claim or been involved in a personal injury lawsuit before?

Examples include car accidents, workers' compensation claims, slip/trip and fall incidents, dog bites, or similar matters.

Yes No

How many prior claims or lawsuits?

Approximate answers are okay. If you do not remember exact years, attorney names, or details, provide your best estimate.

Claim 1

Year

Attorney or Law Firm

Type of claim

Describe the type of claim

Brief description of your injuries (include body part)

Resolved?

Yes No

Claim 2

Year

Attorney or Law Firm

Type

Describe

Brief description of your injuries (include body part)

Resolved?

Yes No

Claim 3

Year

Attorney or Law Firm

Type

Describe

Brief description of your injuries (include body part)

Resolved?

Yes No

Claim 4

Year

Attorney or Law Firm

Type

Describe

Brief description of your injuries (include body part)

Resolved?

Yes No

Tell us about the other claims or lawsuits

Please include the year, the attorney or law firm, the type of claim, and your injuries for each one.

Social Media

Insurance adjusters and defense attorneys routinely review social media after a collision. Posts about daily activities, photos, even check-ins can be used to minimize injury claims. Helping us understand what's publicly visible now lets us protect your case before it becomes an issue. If you're unsure what's on an account, guess, and we can refine later.

Have you posted anything about this collision or your injuries on social media?

Yes No

Describe what was posted and on which platform

Since this collision, have you posted about your daily activities on social media (trips, workouts, events, etc.)?

Yes No

Describe what was posted and on which platform

Which social media accounts do you have?

Check every platform you use. Adding a username or handle is optional.

Facebook

Instagram

TikTok

X (Twitter)

Snapchat

YouTube

Other

Additional Notes

Is there anything else about the collision, your injuries, or your situation that you'd like us to know?

Upload Your Documents

Have any of these handy? Add them here and we'll fill in part of the form for you. This step is optional. You can skip it and type everything yourself.

You can type everything in yourself.

We will ask you for each of these details on the next few steps. If you change your mind, choose Show upload zones above.

Files you already added are still attached. Choose Show upload zones if you want to remove them.

Driver's license, or any photo ID from the government A photo or PDF file

Health insurance card A photo or PDF file

Photos & Reports (if available)

Incident reportIf the place where you fell gave you one.

Photos of where it happened Photos or PDF files. You can add more than one.

Photos of what made you fall Photos or PDF files. You can add more than one.

Photos of your injuries Photos or PDF files. You can add more than one.

Photos of your shoesThe exact shoes you had on that day.

Emergency Contact

If there's an emergency and we can't reach you, who should we call?

Name

Phone

Relationship

The Incident

What date did this happen?

Which day of the week?

What time did the incident occur?

What kind of place was it?

What kind of place?

What's the name of the place?

Street address

City

State

Zip

Where on the property did it happen?

Property Ownership

Who owns the property? (company or person's name)

How can the owner be reached? (phone, address, anything you have)

Who runs the place day to day?

Manager's contact info (phone, address, email - anything you have)

Did you talk to anyone in charge that day? If so, what was their name and job?

Why You Were There

Why were you there that day?

Why were you there?

Had you been to this place before that day?

Yes

What You Were Wearing

Please don't throw away the shoes or clothes you had on that day. We may need them as evidence.

What kind of shoes were you wearing?

What clothes were you wearing? (a rough description is fine)

Do you still have the shoes and clothes you wore that day?

Yes

Some

What's missing, and what happened to it?

What Caused Your Fall

In a few words, what caused you to fall or get hurt?

Tell us more about what was unsafe.

If you know, how long had the problem been there before you fell?

How was the lighting at the time?

If you were outside, what was the weather like?

Describe the weather

Did the Property Know?

These questions help us find out whether the place knew about the problem before you fell. It's okay if you're not sure. Just answer what you can.

Do you know if anyone had complained about this problem before you got hurt?

Yes

Unknown

Do you think the staff or owner knew about the problem before you fell?

Yes

Unknown

If yes, who knew and how do you know that?

Reporting at the Scene

Did you tell anyone who works there what happened? (Even if no one wrote anything down.)

Yes

Who did you tell? (their name and job, if you know)

Who You Were With

This is about the people who came with you that day, like your spouse, a family member, or a friend. They often saw what happened. (We'll ask about other people who saw it, like strangers or staff, in a later step.)

Was anyone with you when it happened, like your spouse, a family member, or a friend?

Yes

How many people?

Their names, and how you know them

Tell Us What Happened

In your own words, tell us what happened.

Evidence at the Scene

Did anyone who works there fill out a report, like a manager writing down what happened?

Yes

Unknown

Who wrote it down? (their name or job, if you remember)

Did they give you a copy of the report?

Yes

Unknown

Did you or anyone take photos or videos of where it happened, or of what made you fall?

Yes

Who took them?

Photos or videos of the place and of what made you fall You can add more than one. Photos, videos, HEIC and MOV files are all fine.

Were there any security cameras at or near the place?

Yes

Unknown

Where were the cameras, and what did they look like?

Did you give a statement to anyone at the scene, like a manager, security guard, or insurance person?

Yes

Unknown

Who did you give a statement to?

Witnesses

Now we're asking about other people who saw what happened, people you didn't come with. That could be other customers, staff, security guards, or anyone nearby who saw it. (If a family member or friend came with you, we already wrote them down earlier, no need to list them again here.)

Did anyone else see what happened, someone you didn't come with?

Yes No I don't know / don't remember

About how many people?

Witness 1

Witness Name Witness Phone

Witness 2

Witness Name Witness Phone

Witness 3

Witness Name Witness Phone

Witness 4

Witness Name Witness Phone

Tell us about the other witnesses

Please include a name and a phone number for each one, one per line.

911 Response

Did anyone call 911?

Yes

I don't know / don't remember

Who called 911?

Do you know why 911 wasn't called?

Medical Response at the Scene

Did paramedics or an ambulance come?

Yes

I don't know / don't remember

Which ambulance company, if you know?

Did you go to the hospital straight from there?

Yes

Which hospital did you go to?

Where did you go afterward? If you went to a hospital first, tell us where you went after you left the hospital.

Where?

Injuries & Symptoms

What parts of your body were hurt, and how do they feel now?

Mark where it hurts

Draw on the areas of your body that hurt. Pick a color for how bad the pain is. This is optional.

Mild Moderate Severe

Marked areas

Nothing marked yet.

When did your symptoms begin?

Review & Submit

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What happened?

Let's talk first

Let's get your case started.

Upload Your Documents

Other Driver's Documents (if available)

Other Documents (if available)

Getting Started

Your Information

Contact & Address

Address

Emergency Contact

Collision Date & Time

Vehicles & Impact

Trip Context

Collision Location

Your Movement

Other Driver's Movement

Describe the Collision

Roadway & Weather Conditions

911 & Police

Ambulance

Statements & Fault

Photos & Cameras

Witnesses

Witness 1

Witness 2

Witness 3

Witness 4

Vehicle Basics

Vehicle Damage / Towing / Rental

Your Auto Insurance

Driver's/Your Insurance Policy

Registered Owner's Insurance (if different)

Your Own Car Insurance (if separate from driver's)

Coverage Details

Other Driver Information

Other Driver's Personal Information

Other Driver's Vehicle

Other Driver's Insurance

Additional Drivers

After the Collision

Injuries & Symptoms

Marked areas

Medical Care So Far

Hospital

Urgent Care

Doctor

Chiropractor / Physical Therapy

Diagnostics

Health Insurance

Primary Care Physician / Family Doctor

Work & Wages

Prior Similar Complaints

Prior Complaint 1

Prior Complaint 2

Prior Complaint 3

Prior Claims/Lawsuits

Claim 1

Claim 2

Claim 3

Claim 4

Social Media

Additional Notes

Upload Your Documents

Photos & Reports (if available)

Emergency Contact

The Incident

Property Ownership

Why You Were There

What You Were Wearing

What Caused Your Fall

Did the Property Know?

Reporting at the Scene

Who You Were With

Tell Us What Happened

Evidence at the Scene

Witnesses