Get Intake Sheet Premises Liability (mold) - Terry Law Group

Filling out the Intake Sheet for premises liability related to mold can be a straightforward process. This guide will help you navigate each section of the form with ease, ensuring you provide all necessary information accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the date on which you are filling out the form in the designated field.
3. Provide the name of your lawyer and the date you discovered the mold in the respective fields.
4. In section I, enter your personal information. This includes your full name, date of birth, preferred nickname, address, phone numbers, email, driver’s license number, social security number, marital status, and spouse’s name if applicable.
5. In section II, fill out your employment information, including your employer’s name, job position, supervisor's name, and work contact information. Indicate if you’ve lost wages and provide details about your hourly salary, commission, and potential time lost from work.
6. Section III requires you to enter your health insurance details. List your primary and any secondary insurance providers with the corresponding member numbers.
7. In section IV, provide the names and contact information of your health care providers, detailing the dates of treatment and any relevant treatment experiences.
8. Next, describe your symptoms or injuries related to mold exposure in section IV-B.
9. In section IV-C, fill in information about the homeowner, landlord, or property manager, including names, addresses, and insurance details.
10. Detail the facts of the incident, including when and where you first noticed the mold, your symptoms' onset, and pertinent medical provider details.
11. Provide any available evidence regarding whether the property owner knew or should have known about the mold, including any photographs or witnesses.
12. In section F, document any prior accidents or injuries that may be relevant.
13. Lastly, in section G, share any additional information that you feel is important for your case, and indicate how you heard about the law firm.
14. After completing all sections, review your entries for accuracy. Save your changes and proceed to download, print, or share the completed form as needed.

Start completing your documents online today for a smooth and efficient process.