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Client Intake

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Name(Required)
Address(Required)
MM slash DD slash YYYY
Make sure to enter the full year for your date of birth.
Marriage Status
MM slash DD slash YYYY
Where Did Your Injury Occur?
How Did Your Injury Occur?

Were you transported by an ambulance?
Was a police/accident report taken?
Max. file size: 50 MB.
Do you have health/medical insurance?
Max. file size: 50 MB.
Do you have Medi-Cal or Medicare?
Max. file size: 50 MB.
Do you have car insurance?
Do you have Med-Pay/PIP medical coverage as part of your car insurance policy?
Max. file size: 50 MB.
Max. file size: 50 MB.
Have you lost income as a result of your injuries?
(please provide a copy of 4 payroll stubs prior to the accident)
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Employer’s address
Are you currently working?
Expect to return to work?
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Richard Willis, PC
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750 B Street, Suite 1760 , San Diego, CA 92101
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Return home Richard Willis, PC
619.237.9800
  • Home
  • Our Team
    • John T. Richards, Esq.
    • Evan Willis, Esq.
  • Maui Wildfire Legal Help
  • Eaton Fire Help
  • Results
  • Practice Areas
    • Practice Areas Overview
    • Brain Injury
    • Construction Defect
    • Homeowner Claim Fire/Flood
    • Insurance Bad Faith
    • Personal Injury
    • Railroad Injury FELA
    • Spinal Cord Injury
  • Contact
Close Menu
  • Home
  • Our Team
    • John T. Richards, Esq.
    • Evan Willis, Esq.
  • Maui Wildfire Legal Help
  • Eaton Fire Help
  • Results
  • Practice Areas
    • Practice Areas Overview
    • Brain Injury
    • Construction Defect
    • Homeowner Claim Fire/Flood
    • Insurance Bad Faith
    • Personal Injury
    • Railroad Injury FELA
    • Spinal Cord Injury
  • Contact