New Client Questionnaire - Jones Act Please fill out this questionnaire in full. If you have any questions while you are completing the questionnaire, please call us atour world-wide toll free number 1-800-JonesAct. A trained legalprofessional will assist you in completing this form. After the formis completed in full, fax or mail it to our office. Personal Information Name (Last, First, M.I.)  Sex (circle)  Male    Female Present Address  Phone Number  Permanent Address  Phone Number  Relative or Friend Who Will Know How to Reach You (Address and Phone Number)  Social Security #  Z #  Union  Place of Birth  Height  Citizenship  Weight  Marital Status  Spouse's Name  Reason for Leaving Vessel  Type of Articles  Fit for Duty?  If Yes, Date Returned to Duty  Work Record Occupation  Years Experience  Certificates and Licenses  Ever been logged, arrested, convicted, or charged by the Coast Guard?  If Yes, Explain  Work Record for Past 5 Years  Wages Information Average Annual Earnings  Where IRS Returns are Filed  Was M&C Received?  How Much?  From  To  Unearned Wages Recieved?  How Much?  To When?  Vessel Information Vessel  Type  Rating  Owner / Operator  Name & Rank of Officer in Charge  Name & Rank of Immediate Supervisor  Signed On Date  Port  Signed Off Date  Port  Watch  If flown to vessel by helicopter, nearest port or place of departure  Treatment/Injury/Doctor Information Doctor Information Medical Attention on Ship By  Treatment in Port By  Treatment Providers  Medical Slip Given  Medical Exam Before Signing On  Date of Exam  Examining Doctor  Address  Prior Medical & Claims History  Injury Circumstances Statute of Limitations  Last Port Vessel Departed from Prior to Injury  Body of Water Vessel Was Navigating at Time of Injury  Distance of Vessel from Shore at Time of Injury  Weather Conditions  Sea Conditions  Injury Information Date of Injury  Time of Injury  Describe Injury in Detail  Liability Facts (Include Location on Ship, Conditions on the Scene, Facts Demonstrating Negligence  and Unseaworthiness)  Miscellaneous Information  Witnesses to Accident (State Nature of Each Witness and Knowledge. Not Limited to Eyewitnesses. Include All Persons Having Knowledge of Accident, Conditions, or Disability. Include Addresses  and Phone Numbers.)  Injury Filings Were Reports Made?  By Whom?  Date Reported  Time Reported  Have Statements Been Signed?  Prepared By?  Papers needed from client: Discharge from Ship, All Prior Discharge Papers, Tax Returns for Past 5 Years, Duty Status Slips / UFFD / ETC., Pay Vouchers, All Medical Records, Logs, Accident Recordes, Crew Lists, etc. Your Signature: Today's Date: Signature of Interviewing Legal Assistant/Attorney: Copyright 2002, True Spring, L.P. d/b/a Note to Client The State Bar of Texas investigates and prosecutes professional misconduct committed by Texas Attorneys. Although not every complaint against or dispute with a lawyer involves professional misconduct, the State Bar Office of the General Counsel will provide you with information about how to file a complaint. For more information, call 1-800-932-1900.