Auto Accident Injury Intake

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Auto accident injury intake form

Email *

Your full legal name *

Your full address, including county *

Phone number *

Date of Accident *

YYYY

Name of city and county where accident occurred. *

Do you have personal injury protection or medical payments on your auto insurance? *

Name(s) and contact info of other drivers/passengers involved in the accident *

Was there an accident report done? *

Who was at fault for the accident? *

State the name and policy number for the other driver's insurance *

Briefly, describe what happened *

Briefly, describe the type of injuries you sustained from this accident *

Have you had similar injuries prior to this accident? If so, for each injury list approximate dates you were injured, a description of the injury, how you were injured, the type of treatment or medication you took, and when the injury was resolved. *

Were you or anyone else transported by ambulance *

Were the vehicles able to be driven after the accident or did they get towed? *

List the places and dates that you sought medical treatment *

Have you been diagnosed, treated, or prescribed anything? If so, list the diagnosis, types of treatment, and prescriptions. *

Have you spoken with any insurance company or made a claim yet? *

Did you agree with the insurance company to settle any portion of your claim? If so, briefly explain. *

What is the status of your vehicle? Has an adjuster evaluated your vehicle for damages yet? *

Do you have photos of the vehicles, people or injuries related to this accident? *

Do you have health insurance? If so, state the name and policy information. *

Have you been in an accident previously? If so, briefly indicate the cause and approximate date of the accident. *

Have you ever been involved in a lawsuit? If so, briefly indicate what it was for, the approximate date it was filed and resolved, and the outcome. *

A copy of your responses will be emailed to the address you provided.

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