4615 Sherman Street

Houston, Texas 77011

Ph: (713) 804-9118

Fax: (346) 585-0121

Email: ngiles@pinnaclelawgrouphtx.com

Thank you so much for contacting the law office of Nicholas Giles! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you! To return to the website, please click here.

PERSONAL INFORMATION

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Social Security #

Driver's License

Spouse's full name, if married

Military Service?

Yes

ACCIDENT INFORMATION

IF APPLICABLE

Is this an auto accident?

Yes

Driver or Passenger?

Date of incident

Time of Incident: AM or PM?

City of incident

County of incident

Road/Intersection (if applicable)

Were the police called to the scene?

Yes

Was an accident or incident report filed?

Yes

Describe how the incident occurred

Photo / Diagram upload

Add attachment

OTHER PARTY If KNOWN/ APPLICABLE

IF KNOWN/ APPLICABLE

Name of the other party

Address

Phone number

His / Her job

His / Her age

Did he/she have insurance?

Yes

Do you know what the other party’s financial circumstances are without regard to any insurance he/she may have?

Yes

Give your observations about the party as a person

How did the defendant’s car leave the scene? If towed, state by whom and where taken?

AUTOMOBILE INFORMATION

IF APPLICABLE

What is the make, model, and year of your car?

Who was the operator of your car?

What is the license plate number of your car?

What was the damage to your car?

Did you have to rent a car?

Yes

What is the make, model, and year of the other party’s car?

Who was the Operator of that car?

What was the license plate number of that car?

What was the damage to that car?

Who investigated the accident?

Police

State Patrol

Sheriff

No Investigation

Describe the point of impact for each auto

How far did the cars travel after impact?

Position of vehicles after impact

How did you leave the scene of the accident?

PASSENGERS

IF APPLICABLE

Passenger #1: (if applicable, please select "Yes" and fill out the following information)

Yes

Passenger #2: if applicable, please select "Yes" and fill out the following information)

Yes

Passenger #3: if applicable, please select "Yes" and fill out the following information)

Yes

Passenger #4: if applicable, please select "Yes" and fill out the following information)

Yes

Passenger #5: if applicable, please select "Yes" and fill out the following information)

Yes

Additional Details:

WITNESSES

IF APPLICABLE

Witness #1: (if applicable, please select "Yes" and fill out the following information)

Yes

Witness #2: (if applicable, please select "Yes" and fill out the following information)

Yes

Witness #3: (if applicable, please select "Yes" and fill out the following information)

Yes

Witness #4: (if applicable, please select "Yes" and fill out the following information)

Yes

Witness #5: (if applicable, please select "Yes" and fill out the following information)

Yes

STATEMENTS MADE

Have you told any police officer, investigator, insurance adjuster or any other person about the collision? Please list each person and the entire substance of your statement.

Statement Details

AUTOMOBILE INSURANCE INFORMATION

Please provide complete and accurate information about your automobile insurance carrier, including policy number, coverage types (e.g., liability, PIP, UM/UIM), and contact details.

Name of your auto insurance carrier

Name of policy holder

Policy number

Agent / adjuster

Telephone number

Claim number (if known)

Type of coverage

Personal Injury Plan (PIP) limits

INJURIES

Please describe any and all aches, complaints, discomforts and disabilities, as a result of accident related injuries, in detail

Injury Description

Did you go to the hospital?

Yes

Did you go by ambulance?

Yes

Did they take x-rays?

Yes

Have you seen a doctor since the date of the accident, other than at the emergency room?

Yes

INJURY HISTORY

Have you had any accidents or injuries before this accident?

Injury #1 (if applicable, please select "Yes" and fill out the following information)

Yes

Injury #2 (if applicable, please select "Yes" and fill out the following information)

Yes

Injury #3 (if applicable, please select "Yes" and fill out the following information)

Yes

Injury #4 (if applicable, please select "Yes" and fill out the following information)

Yes

LOSS OF EARNINGS

If you anticipate loss of earnings due to accident related injuries, please complete the following:

Employer

Your position or title

Rate of pay: $ ____ per hour

Rate of pay: $____ yearly salary

How many hours do you normally work per week?

ADDITIONAL INFORMATION

Any additional Information you think would be helpful

THANK YOU

If you have completed the form, please click SUBMIT.