Full Name: *
Social Security Number:
Date of Birth:
Time of Day:
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?
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?
Have you been questioned by an insurance adjuster or investigator?
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.
Relationship (if any):
Make and Model:
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?
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?
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?
Name of Hospital:
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?
Medical Appliances Expense:
Medical Appliances Amount:
Property Damage Expenses:
Property Damage Amount:
Name of your automobile insurance company:
All Vehicles Listed on Policy:
Do you have Personal Injury Protection coverage?
Do you have Uninsured Motorist coverage?
Do you have Medical Payments coverage?
Do you have Collision coverage?
Do you have health insurance?
Name of health insurance company:
Were you injured on the job in this accident?
Are you receiving payments for workers compensation?
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?
Have you received Medicare benefits as a result of this accident?
What education have you had, including any special employment training?
Were you employed at the time of the accident?
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?
If no, what is the reason for the termination of employment?
Have you missed any time from work as a result of your injury?
If yes, what dates were you unable to work because of your injury:
Did you lose wages for work missed because of this accident?
If so, state the total loss to date:
Have you received any increases or decreases in your pay since the accident?
If yes, explain:
Have you ever served in the military?
If yes, which branch?
Dates of Service:
Any service-connected injuries or disabilities?
Present condition of service-connected injury or disability:
Do you receive payments for service-connected injuries or disability?
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:
Was a lawsuit filed?
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.**
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?
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?
Type of Accident:
Name of Facility/Physician:
Nature of treatment:
Date care began: