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CAR ACCIDENT
INTAKE FORM

BACKGROUND INFO

*Full name

*Email

*Cell Phone

Home phone

Work Phone

Country/Region

Address

Address - line 2

City

Zip / Postal code

Date of birth

SS#

Date of the accident

Time of the accident

:

Health insurance

Working at the time?

Yes

No

If yes, making a comp claim?

Yes

No

What state did the accident happen in?

Street

County

Driver

Passenger

Pedestrian

If driver, other passengers?

Description of the accident

TREATMENT

Which jurisdiction

No police

Officer's name

Police report #

Ambulance

Yes

No

Emergency room?

Yes

No

What hospital

Name(s) of witiness(es)

Addresses & phone numbers

INJURIES

Body parts injured in the accident

FOLLOW UP TREATMENT

Doctors name

Doctor's phone

Dates

to

Other treatment

Prior injuries or accidents

Losing time from work?

Yes

No

Name of employer

Occupation

Number of hours lost

DEFENDANT'S CAR

D - Make

D - Model

D - Year

D - Tag #

D - State

D - Driver

D - Owner

D - Insurance company

D - Policy #

D - Claim #

D - Adjuster

D- Adjuster Phone

VEHICLE OUR CLIENT WAS IN (PIP/UIM)

P - Make

P - Model

P - Year

P - Tag #

P - State

P - Driver

P - Owner

P - Insurance company

P - Policy #

P - Claim #

P - Adjuster

P- Adjuster Phone

Are you a licensed driver?

Yes

No

Do you have auto insurance?

Yes

No

Name of insurance carrier

Policy #

Describe property damage:

Property P car

Property D car

Photos of vehicle?

Yes

No

Advise client to get photos?

Yes

No

Location of car

Is car drivable?

Yes