Israel & Israel Oklahoma Attorney's / Litigation Page

Date of accident or occurrence:

Do you contend this was a
work-related injury?

Yes NO

If YES, The Employer Name:

Employer Address:

Employer City:

State:

Have you ever received and injury to this area of you body before:

YES NO

Location of accident or occurrence:

Is this a vehicle related accident

YES NO

If YES, Where you the vehicle:

Passenger Driver

Was a Citation Issued?

YES NO

If YES, To whom?

How much insurance does the party at fault have?

How much uninsured motorist do you have:

Approximate amount of medical bills to date:

Approximate amount of future medical bills expected:

Past amount of lost wages:

Future amount you expect to lose in wages:

Chief Physical Complaints:

Do you claim any disability from Fen-Phen or Redux?

YES NO

If YES, How long did you take the drug?

Did you take an Echocardiogram

YES NO

If YES, What were the results?