INTAKE REPORT AND INJURY STATEMENT
Sign in to Google to save your progress. Learn more
Email *
ACCIDENT PHOTOS
property damage
scene
client
injuries
select:
INDEX INFO:
date contract signed:
MM
/
DD
/
YYYY
investigator:
source in/how did you hear about us:
language:
engl
span
rus
select
DATE OF ACCIDENT: *
MM
/
DD
/
YYYY
driver
passenger
rider
pedestrian
select one
Clear selection
CLIENT  NAME
first: *
middle:
last: *
ok to discuss with spouse:
yes
no
N/A
select one
Clear selection
spouse name:
CONTACT INFO:
street: *
unit no.:
city: *
state: *
zip: *
phone 1: *
phone 2:
e-mail:
date of birth: *
MM
/
DD
/
YYYY
social security no.:
000-00-0000
driver license no.:
EMERGENCY CONTACT:
full name: *
phone: *
CLIENT INSURANCE:
carrier: *
(if none - put N/A)
policy no.: *
(if none - put N/A or unknown)
claim no.: *
(If none - put N/A or unknown)
collision coverage:
yes
no
N/A or unknown
select one
Clear selection
if yes, specify limits:
rental coverage:
yes
no
N/A or unknown
select one
Clear selection
if yes, specify limits:
MedPay:
no
yes
N/A or unknown
select one
Clear selection
if yes, specify limits:
UM/UIM:
no
yes
N/A or unknown
select one
Clear selection
if yes, specify limits:
ADJUSTER NAME
(Your insurance adjuster)
first:
last:

CLAIM ADJUSTER CONTACT:

tel.:
fax:
street:
suite no.:
city:
state:
zip code:
e-mail:
CLIENT VEHICLE:
(vehicle you were in at the time of the accident. If none - put N/A)
make:
model:
year:
color:
state/license plate no.:
regular owner:
(full name)
repair shop :
phone:
describe damages:
minor
moderate
major
select one
Clear selection
ACCIDENT INFO:
city and state: *
date: *
MM
/
DD
/
YYYY
time:
Time
:
location:
(i.e. freeway, street address, intersection, alleyway)
weather:
(i.e. clear, sunny, foggy, rainy, snowy, dark)
road condition:
(i.e. light or heavy traffic, construction work, poor street lighting)
seat belt in use:
yes
no
N/A
select one
Clear selection
airbags deployed:
yes
no
N/A
select one
Clear selection
hit anything inside the car:
(i.e. headrest, steering wheel, side door)
yes
no
N/A
select one
Clear selection
if yes, describe:
car seat:
yes
no
N/A
select one
Clear selection
# of passengers:
POLICE REPORT:
(only if applicable)
law enforcement agency:
phone:
report no.:
officer name:
badge no.:
BRIEF ACCIDENT DESCRIPTION:
(i.e. traveled from/to, route taken, direction of travel, lane of traffic, lane change, traffic signals, car speed at the time of collision, how the accident happened, point of impact, was your car moving or stopped, any exchange of information with other people, admission of fault)
do you have kids:
yes
no
select one
Clear selection
their ages:
driving for a ride-sharing app:
yes
no
select one
Clear selection
which one:
driving within the scope of emplmnt:
yes
no
select one
Clear selection
client health info/injuries:
ambulance:
yes
no
select one
Clear selection
emergency room:
yes
no
select one
Clear selection
MEDICAL FACILITIES VISITED FOR THIS INJURY:
(i.e. hospital, urgent care, primary physician, other medical specialists)
1. name/facility:
1. address:
1. phone:
2. name/facility:
2. address:
2. phone:
3. name/facility:
3. address:
3. phone:
PRIOR ACCIDENTS/INJURIES:
1. describe injury:
1. year:
1. claim filed:
yes
no
select one
Clear selection
1. claim type:
workers compensation
personal injury
select one
Clear selection
2. describe injury:
2. year:
2. claim filed:
yes
no
select one
Clear selection
2. claim type:
workers compensation
personal injury
select one
Clear selection
3. describe injury:
3. year:
3. claim filed:
yes
no
select one
Clear selection
3. claim type:
workers compensation
personal injury
select one
Clear selection
CLIENT MEDICAL/HEALTH INSURANCE INFO:
name of insurance:
state health insurance: *
MediCal
MediCare
N/A
select one
type:
HMO
PPO
other
unknown
select one
Clear selection
group no.:
medical record no.:
adjuster/claim admin:
coverage used for treatment related to this accident:
yes
no
select one
Clear selection
street:
city:
state:
zip:
phone:
fax:
CLIENT EMPLOYMENT INFO:
employer name:
contact name/supervisor:
phone:
street:
suite:
city:
state:
zip:
your position:
years at job:
time missed:
hourly rate:
hours/week:
PARTY AT FAULT (DEFENDANT NAME):
first (or business name): *
middle:
last: *
(if business - put N/A)
DEFENDANT CONTACT INFO:
street: *
apt:
city: *
state: *
zip:
cell:
home:
work:
e-mail:
date of birth:
MM
/
DD
/
YYYY
social security no.:
driver license no.:
driving for employer:
yes
no
select one
Clear selection
DEFENDANT AUTO INSURANCE:
carrier:
policy no.:
claim no.:
limits:
DEFENDANT ADJUSTER NAME:
first:
last:

DEFENDANT ADJUSTER CONTACT:

phone:
ext:
fax:
street:
suite:
city:
state:
zip:
e-mail:
DEFENDANT VEHICLE:
make:
model:
year:
color:
state/license plate no.:
repair estimate:
location:
tow yard:
No. of people in veh.:
describe damages:
WITNESS(es):
witness 1:
phone:
witness 2:
phone:
CLIENT HOBBIES:
(i.e. hiking, exercising, mountain biking, reading, playing sports)
hobbies/activities:
CASE EXPECTATIONS:
(what do you expect out of this case - cover medical bills, receive monetary compensation in the amount of $, provide for future medical necessities, punish liable party, get what’s reasonable under the case circumstances)
expectations:
ADDITIONAL INFORMATION
(if you didn’t answer any of the above questions fully and would like to add more details, please specify the question and describe your answer in depth, or write additional information about this case that you deem important)
additional info:
INJURY STATEMENT:
  Date  
MM
/
DD
/
YYYY
Client Name:  
Nature of Injury:  
Other (Describe)  
Part of body injured or affected (please shade the location and add pain rating)
Please rate your discomfort on a scale of 1-10 (1 = mild pain, 10 = the worse pain you’ve ever felt):  
Head
Clear selection
Neck
Clear selection
Chest
Clear selection
Back
Clear selection
Arm
Clear selection
limited range of motion:
neck
back
arms
legs
select
Procedures performed for this injury:
Psychological issues related to the accident:
Other  
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms