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Kenneth Vercammen & Associates
A Law Office with Experienced Attorneys for Your New Jersey Legal Needs

2053 Woodbridge Ave.
Edison NJ 08817

Personal Injury and Criminal
on Weekends 732-261-4005

Princeton Area
68 South Main St.
Cranbury, NJ 08512
By Appointment Only
Toll Free 800-655-2977

Personal Injury Fact Sheet/Personal Injury Interview Form If Injured in an Accident

Todays date: _________________________________

Plaintiff name: _________________________________

Address: _____________________________________



Phone Number: _______________________________

Email: ________________________________________

d/o/b: ________________________________________

Soc.. security: __________________________________

Spouse _______________________________________

2a. Date of Accident: _____________________________

town, county, state: _______________________________

day of week _____________________________________

time: _________________________________

weather _________________________________

Road conditions _______________________________________________________________________

Description of Accident: _________________________________________________________________





2b. Operator of Plaintiffs car: _____________________________________________________________

Owner of Plaintiffs car: __________________________________________________________________

2c Other occupants of Plaintiffs car. ________________________________________________________

2d Street Plaintiff was traveling on: __________________________________________________________

Direction of travel (ex- North, south, etc.): ____________________________________________________

Nearest approaching road: ________________________________________________________________

2e Street Defendant was traveling on: ________________________________________________________

Defendant Direction of travel (ex- North, south, etc.): ____________________________________________

Nearest approaching road: ________________________________________________________________

2f Traffic lights or stop signs in area: _________________________________________________________













6- X-RAYS, TAKEN BY: _________________________________

ADDRESS: ____________________________________________________________________________

DIAGNOSTIC TESTS: ___________________________________________________________________

X-ray, MRI DATE _________________________________

RESULTS _________________________________

7 DOCTOR-NAME _________________________________

ADDRESS PHONE DATES OF TREATMENT: _________________________________

DATE OF REPORTS: _________________________________

7B. MEDICAL PROVIDER-NAME __________________________

ADDRESS PHONE DATES OF TREATMENT: _________________________________

DATE OF REPORTS: _________________________________


DATE OF REPORTS: _________________________________



10. Employer Name: __________________________________ Address: ____________________________________________

Job/Position Gross/week Net/week Time Lost Total Wages Lost: _____________________________________________________

11. IF RETURN TO WORK: _________________________________ Current Employer Name: _________________________________

Address: _________________________________ Job: _________________________________ ______________ Gross/week Net/week


13. Medical bills, Doctor Amount unpaid Paid hospital bills, medicine, etc. Total medicals (As of ________): _________________________________


15. Relevant Documents: __________________________________________________________________
Identify all documents that may relate to this action, and attach copies of each such document, such as police report, hospital bills, etc.

Police Report: _____________________________________________________________________________

Declaration Sheet: __________________________________________________________________________

Hospital Bills: ______________________________________________________________________________

Hospital Records: ___________________________________________________________________________

Medical Bills and Records: ____________________________________________________________________

Photographs of Accident Site: __________________________________________________________________

Photographs of Damage to Plaintiffs car: __________________________________________________________

Photographs of Damage to Defendants car: ________________________________________________________

Photographs of Injuries, scars, cuts: _______________________________________________________________

Repair damage estimate: _______________________________________________________________________

Other: _____________________________________________________________________________________

16a defendant name: _________________________________ _________________________________ address: _______________________________

_________________________________ Owner of Def car: _________________________________ address: _________________________________

Type of car: _________________________________ ___________________________ make, year Other occupants of def car

16b Eye witness name: _________________________________ address & phone: _________________________________

17 Names and addresses of People with Relevant Knowledge

Officers of Investigating Police Department: _________________________________

18. Photographs: _________________________________ _________________________________ If any photographs, videotapes, audio tapes or other forms of electronic recordings, sketches, reproductions, charts or maps were made with respect to anything that is relevant to the subject matter of the complaint, describe: _________________________________ _________________________________ (a) the number of each; (b) what each shows or contains; (c) the date taken or made; (d) the names and addresses of the persons who made them; (e) in whose possession they are at present; and (f) if in your possession, attach a copy, or if not subject to convenient copying, state the location where inspection and copying may take place. ___________

19. If you claim that the defendant made any admissions as to the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date made; (b) the name of the person by whom made; (c) the name and address of the person to whom made; (d) where made; (e) the name and address of each person present at the time the admission was made; (f) the contents of the admission; and (g) if in writing, attach a copy.

20. If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication.

21. If you have obtained a statement from any person not a party to this action, state: _________________________________ _________________________________ (a) the name and present address of the person who gave the statement; (b) whether the statement was oral or in writing and if in writing, attach a copy; (c) the date statement was obtained; (d) if such statement was oral, whether a recording was made, and if so, the nature of the recording and the name and present address of the person who has custody of it; (e) if the statement was written, whether it was signed by the person making it; (f) the name and address of the person who obtained the statement; and (g) if the statement was oral, a detailed summary of its contents. _____________________________

22: _________________________________ ___________________________ Violation by Defendant of Motor Vehicle law (i.e. Careless driving or other statute

23. Expert witnesses: _________________________________ 24. Have you every been indicted and convicted of a crime? ______ (This question required by Rules of Court)

25a Plaintiff car ins company: _________________________________ THRESHOLD address: _________________________________ phone: _________________________________ policy # claim # year, make, model collision coverage Who Notified? UM/ UIM coverage

25b Named Insured: _________________________________ _________________________________ _____________________________________

25c Copy of Dec Sheet: _________________________________

25d. Plaintiffs private major- medical ex- Blue Cross address: _________________________________ phone: _________________________________ Policy number

26a: Distance between Plaintiff and point of impact when first observed other vehicle and Plaintiffs speed: _________________________________

26b: distance between Plaintiff and the Defendants vehicle when first observed other vehicle: _________________________________ ___________________________________________________________

26c: Where Plaintiffs vehicle came to rest and where Defendants vehicle came to rest: _____________________________ ___________________________________________________________

27: Part of Plaintiffs car hit by Defendants car: _________________________________ ________________________________________________________

Damage to Plaintiffs car: _________________________________ _________________________________ _______________________________________

Property damage estimate: _________________ ___________________________________________________________

28: Where Plaintiff was coming from and where Plaintiff was going to: _________________________________ ___________________________________________________________

29. Parts of body hitting car: _________________________________ _________________________________ _____________________

30. Unconsciousness? _____________________

31. Skid marks by any car: _________________________________ _________________________________ _____________________

32. Defendants Ins carrier 33. address: _________________________________ phone: _________________________________ 34. adjuster: _________________________________ 35. Policy limits: _________________________________ claim #: _________________________________

36. When did you apply your brakes?: ___________________________ _________________________________ _____________________

37. How fast were you going?: _________________________________ _________________________________ _____________________

38. How fast was the Defendant going?: _________________________________ _________________________________ _____________________

39. Describe the position of each car at the point of impact, giving distance from curb, lines, streets or other landmarks?: _________________________________ _________________________________ _____________________

40. Alcoholic beverages or medication within 12 hours before accident? _______

41. Prior accidents involving injury in which you received an insurance settlement or suit was started? (Including workers compensation)? Prior car accidents with only property damage? _____________________

42. Negligent actions by Defendant: _________________________________ _________________________________

43. What else did you tell police? _____________________

44. Set forth the names of insurance agents and other individuals you discussed the case with an what did you say? _____________________

45. Please prepare a Diagram of the accident site _____________________

46. Are you receiving Medicare/ Medicaid? ___________ Are you receiving SSI? ___________

Is there anything else important? ___________________________

___________________________________________________________ ___________________________________________________________

Documents to be supplied to attorney & in his possession: Police Report: _________________________________ Declaration Sheet: _________________________________ Medical/ Hospital Bills and Records: _________________________________ Photographs of Accident Site: _________________________________ Photographs of Damage to Plaintiffs car: ___________________________ Photographs of Damage to Defendants car: _________________________________ Photographs of Injuries, scars, cuts: _________________________________ Repair damage estimate: _________________________________

Cell Phone:
E-Mail Address

If You Do Not Include a Complete E-Mail Address, Network will not Forward Your Contact Form to the Law Office.

Details of the Case
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Kenneth Vercammen was the Middlesex County Bar Municipal Court Attorney of the Year

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Since 1985, KENNETH VERCAMMEN has worked as a personal injury attorney, working for injury victims and their families. By taking a hard-hitting, aggressive approach toward the insurance companies, KENNETH VERCAMMEN and our co-counsel have consistently obtained outstanding results for many injured clients over the years I am proud to have worked on cases in various capacities, small and large. While obviously prior results cannot guarantee the outcome of future cases, I can guarantee that you case will receive the same degree of dedication and hard work that went into each of these prior cases.

In direct contrast to the hard-hitting approach we take toward the insurance companies is the soft approach we take toward our clients. I am proud of my compassionate staff as I am of the outstanding financial results they have achieved. For many years, I have watched them treat our clients with patience, dignity and respect. I would have it no other way.

Many years ago, I attended a seminar sponsored by the American Bar Association on Law Practice Management. This was to help insure that each of our clients is always treated like a person -- not a file! We recognize that you are innocent victims and that you have placed your trust in us. Please understand that we understand what you are going through. Feel comforted that we are here to help you.

If you retain KENNETH VERCAMMEN to represent you, we will give you the same advice we give each of our clients -- concentrate on your life, you family and your health. We will take care of everything else. Leave all of the work and worry about your legal rights to us. Trust us. Believe in us. Have faith in us as your attorneys. Understand that we will always to do what we believe is best for you and your case. Helping you is our job. In fact, it is our only job -- guiding injury victims like you through one of the most difficult times of your lives, with care and concern -- while fighting aggressively to the limits of the law to obtain compensation and justice for each of you!

Print our Personal Injury Questionnaire on our Website, Fill it out and Fax back, so we can determine if we can help you obtain an injury settlement. We would welcome an opportunity to prove to you what we have proven to thousands of injured clients -- that you can feel comfortable and secure in the fact that KENNETH VERCAMMEN - Trial Attorney We Fight To Win.

When you have been injured in an accident or collision, you are worried about who is going to pay your medical bills, lost wages, and other damages. The last thing you want is to be taken advantage of by an insurance company. If you dont protect your rights, you may not be able to make a claim.

Insurance companies have attorneys and adjusters whose goal is to pay you as little as they can. You need a New Jersey personal injury lawyer to fight for you. I am dedicated to helping your recover as much money as possible under the law.

You need an attorney who will work hard to protect your rights, maximize your insurance settlement and minimize the hassles of dealing with the insurance companies. You need an experienced and aggressive New Jersey trial lawyer with PROVEN RESULTS who will fight for you. Having an experienced personal injury lawyer can make the difference between getting what you deserve and getting nothing.

Without the threat of a lawyer who is willing to go to trial and seek a big jury verdict, why would an insurance company pay you what your claim is really worth? Lawsuits can be expensive, and many people do not have the money to pursue their claim. In every case, I advance all costs associated with pursuing your case and I do not ask you for a penny until we recover from the other side.

I am an experienced aggressive trial lawyer and a 3rd degree Black Belt. I am not afraid to take your case to trial if that is what it takes to maximize the amount of money your recover for your personal injury. I offer one-on-one service, and I will not hand your case off to an inexperienced lawyer or a paralegal.

Reduce the stress of making a claim.

Personal injury accidents can turn your life upside down. Making a personal injury claim can be difficult and time consuming. Once I take your case, you can stop worrying about dealing with the insurance companies and focus on recovering from your injuries. I take care of all of the paperwork, phone calls, and negotiations, so you can get on with your life.

p.s. For those clients who are afraid or reluctant to go to Court, KENNETH VERCAMMEN also offers a special -- For Settlement Only -- program. This means that if we are unable to settle with the insurance company, we will not go any further -- unless you want us to. You have my personal assurance that there will be absolutely no pressure and no obligation.

We handle personal injury cases on a contingency fee basis.


Call our office to schedule a "confidential" appointment 732-572-0500

Kenneth A. Vercammen is the Managing Attorney at Kenneth Vercammen & Associates in Edison, NJ. He is a New Jersey trial attorney has devoted a substantial portion of his professional time to the preparation and trial of litigated matters. He has appeared in Courts throughout New Jersey each week on personal injury matters, Criminal /Municipal Court trials, and contested Probate hearings.

Mr. Vercammen has published over 125 legal articles in national and New Jersey publications on criminal, elder law, probate and litigation topics. He is a highly regarded lecturer on litigation issues for the American Bar Association, NJ ICLE, New Jersey State Bar Association and Middlesex County Bar Association. His articles have been published in noted publications included New Jersey Law Journal, ABA Law Practice Management Magazine, and New Jersey Lawyer. He is the Editor in Chief of the American Bar Association Tort and Insurance Committee Newsletter.

Admitted In NJ, US Supreme Court and Federal District Court.

Contact the Law Office of
Kenneth Vercammen & Associates, P.C.
at 732-572-0500
for an appointment.

The Law Office cannot provide legal advice or answer legal questions over the phone or by email. Please call the Law office and schedule a confidential "in office" consultation.

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Ken Vercammens Resume
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Copyright 2019. Kenneth Vercammen & Associates, P.C.