Instructions: West Palm Beach Florida car accident client regarding change of circumstances.

Please complete and return this form whenever there has been a change in any circumstances (name, marriage, number of children, address, telephone, medical care or treatment, employment, military service, education, injury, etc.). It is important that we be kept advised of all changes so that we will be able to contact you and continue to evaluate and process your West Palm Beach Florida car accident claim properly for a fair settlement or verdict.

General Information

1. Change of name:

2. Change of marital status:

3. Change of address:

4. Change of telephone number, fax number or E-mail address:

5. Change in other family circumstances (birth of new child, death of immediate family member, etc.):

Employment Information

1. Change of occupation:

2. New work address:

3. New work telephone or fax number:

4. New job duties or responsibilities:

5. Change in salary, benefits or pensions:

Medical Information

1. New family physician:

2. New treating physician:

3. Additional physicians (include chiropractors, psychologists, psychiatrists, etc.) seen since initial interview:

4. Any changes in physical appearance or health since initial client interview:

5. Any new tests or diagnostic studies given to you since initial client interview (provide details):

Education

1. Changes in educational status:

2. New schools, colleges or universities attended:

3. Degrees, diplomas or certifications earned:

Criminal/Arrests/Citations

1. Any criminal charges brought against you since the initial client interview:

2. Nature of charges brought:

3. Disposition of charges brought:

4. Any motor vehicle citations, summons, etc.:

5. Dispositions of such citations or summons:

Other Incidents, Accidents, Workers Compensation Claims or Lawsuits

1. Other incidents/accidents/injuries since initial interview:

2. Have any lawsuits been brought by you as a result of any of those
injuries?

3. Have any claims been brought by you as a result of those injuries (workers compensation, temporary disability claims, etc.)? (Provide details.):

4. Have you been named as a defendant in any lawsuits since the initial client interview? (Provide details.):

5. Please include any other information that has changed and of which we should be aware since the initial interview:

6. What is the best time of day to contact you for follow-up information?

7. How would you prefer to be contacted?
a. telephone (home)_____________________________
b. telephone (work)_____________________________
c. letter ______________________________________
d. fax _________________________________________
e. e-mail ______________________________________

Signature of Client

___________________________________

Date: _____________________________