Full Name: *
Address: *
Phone Number:
Email: *
Social Security Number:
Date of Birth:
Marital Status:
Spouse Name:
Date:
Time of Day:
DaylightDark
City:
County:
Weather Conditions:
Describe the location of the accident (as to intersections or fixed object):
Law Enforcement that investigated the accident:
In your own words, describe the details of this accident, including the time leading up to the moment of the collision:
How did you leave the scene of the accident?
Were photographs or video taken at the scene of the accident? YesNo
If you are not in possession of any photographs or video, what is the name and phone number of the person who has possession of them:
Do you have a Driver Exchange or Crash Report? YesNo
Have you been questioned by an insurance adjuster or investigator? YesNo
Date/Time:
Where:
Name of person who questioned you:
Please list below everything you believe the other driver(s) did that caused or contributed to the cause of the accident.
Please draw a detailed diagram of the accident scene and vehicles to the best of your ability.
Names and phone number of any witnesses or others that may be of assistance to your claims.
Name:
Relationship (if any):
Make and Model:
Model Year:
Name of everyone listed as an owner of this vehicle:
Where is the vehicle now:
Has anyone taken photographs of the damages to the vehicle? YesNo
List all injuries known or believed by you to have been received as a result of this accident:
State your present physical condition — scars, disabilities, deformities, discomforts — resulting from the injuries received in this accident:
Please list any of your usual activities that you have NOT been able to perform since the accident, such as lawn care, golfing, dancing, etc.:
Has anyone taken photographs or videotapes of your injuries? YesNo
If so, state the name and address of the person who took them and the person who has possession of them:
Were you hospitalized as a result of this accident? YesNo
Name of Hospital:
Date Admitted:
Date Discharged:
Please list all Medical Providers who have seen or treated you as a result of this accident:
Name of Facility/Physician:
Nature of Treatment:
Date Care Began:
Still treating at this location? YesNo
Hospital Expenses:
Hospital Amount:
Doctor Expenses:
Doctor Amount:
Therapists Expenses:
Therapists Amount:
Medical Appliances Expense:
Medical Appliances Amount:
Prescriptions Expenses:
Prescriptions Amount:
Ambulance Expenses:
Ambulance Amount:
Property Damage Expenses:
Property Damage Amount:
Miscellaneous/Other Expenses:
Miscellaneous/Other Amount:
Name of your automobile insurance company:
Policy Number:
Claim Number:
Adjuster's Name:
Adjuster's Telephone:
All Vehicles Listed on Policy:
Do you have Personal Injury Protection coverage? YesNo
Do you have Uninsured Motorist coverage? YesNo Amount:
Do you have Medical Payments coverage? YesNo Amount:
Do you have Collision coverage? YesNo
Do you have health insurance? YesNo
Name of health insurance company:
Workers' Compensation
Were you injured on the job in this accident? YesNo
Are you receiving payments for workers compensation? YesNo
Name and phone number of the attorneys who are handling the workers’ compensation case:
Social Security or Medicare
Have you received social security benefits as a result of this accident? YesNo
Have you received Medicare benefits as a result of this accident? YesNo
What education have you had, including any special employment training?
Were you employed at the time of the accident? YesNo
If so, name and address of employer:
What was your job title, or what type of work were you doing?
What is your rate of pay?
How many hours per week were you regularly working before the accident?
When did you first start working for the company listed above?
Have you remained employed since the accident? YesNo
If no, what is the reason for the termination of employment?
Have you missed any time from work as a result of your injury? YesNo
If yes, what dates were you unable to work because of your injury:
Did you lose wages for work missed because of this accident? YesNo
If so, state the total loss to date:
Have you received any increases or decreases in your pay since the accident? YesNo
If yes, explain:
Have you ever served in the military? YesNo
If yes, which branch?
Dates of Service:
Any service-connected injuries or disabilities? YesNo
Details:
Present condition of service-connected injury or disability:
Do you receive payments for service-connected injuries or disability? YesNo
List every claim you have ever made for personal injury or property damage and give details. This includes claims under state workers’ compensation laws, Railroad Sickness Benefits, and the Longshore and Harbor Workers’ Compensation Act. If you have made no claims and filed no lawsuits, state “none.”
**Having previous claims or injuries will not necessarily damage any current claims, it is the denial of them (or failing to disclose) that can harm your potential claim.**
Type of Claim:
Against Whom:
Was a lawsuit filed? YesNo
Result of the Lawsuit:
Please list any prior incident, whether it resulted in a claim for damages or not, stating the date, place, and nature of the accident, and the extent of your injuries. If you have had no prior accidents or injuries, state “none.”
**Having previous accidents or claims will not necessarily damage any current claims, it is the denial of them (or failing to disclose) that can harm your potential claim.**
Place:
Nature of accident or injury:
Body parts injured:
Names of any hospitals or doctors you treated with:
Did you receive any MRIs or other diagnostic tests as a result of these injuries? YesNo
If so, where did you receive the testing, when, and what type of test (i.e. MRI of my neck)
Have you had any accidents or injuries since the accident you are here for now? YesNo
Type of Accident:
Nature of treatment:
Date care began:
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