Motor Vehicle Collision/Injury Questionnaire

Thank you for asking this firm for assistance in your auto accident claim. In order to begin processing your claim, we need to develop the basic information of the events of your collision. All information that you provide is confidential and protected by attorney-client privilege. It is important to be accurate and complete – incorrect or missing information could seriously affect your case in a negative manner! Please fill this form ASAP, keeping a copy for yourself. Please refer to it from time to time. If more or different information is appropriate, please provide this to me.

Today’s Date:

Date of Injury:

Information About You

Name *

Phone*

Secondary Phone

Social Security #:

Date of Birth :

Email Address *

Address

Are You Married?
Yes
No

Are you a minor child?
Yes
No

Spouse's Name:

Spouses SSN:

Website (Facebook, Twitter, Snapchat, etc.) URL:

Are you involved in bankruptcy proceedings? Yes No

If so, what chapter?

Who is your bankruptcy attorney (name, address and phone #)?

Emergency Contact

Who should we contact in the event you cannot be reached?

What is their relationship to you?

What is their primary phone number?*

What is their e-mail?*

What is their address?

Employer Information

What is your occupation?

Who is your employer?

When did you start working there?

How many hours/week?

What is your pay?

What is your work Phone #?

Are you currently out of work due to your injuries?

Did your doctor provide a medical excuse to miss work?

What date did you go out of work?

Return to work?

What was the date of the collision?

Time of Day?*

Did you receive a traffic citation? Yes No

Did the other driver(s) receive a traffic citation? Yes No

Were you working at the time of the collision?

Did the police respond? Yes No

Which Police Department came?

Did the officer write a report? Yes No

Do You have a copy of police report? Yes No

Where were you sitting in the vehicle?

Were you wearing a seat belt? Yes No

If not, why not?

How many vehicles were involved in the collision?

Were other people in the vehicle with you? Where were they sitting?

Were you injured? Yes No

Were other occupants of the vehicle injured? Yes No

Names of Other Injured Occupants, Phone Number:

Medical Information

Was an ambulance called to the collision scene? Yes No

Ambulance Company Name?

Were you transported by ambulance to the hospital? Yes No

Which Hospital?

Were you admitted, or was treatment only in the Emergency room?

How long were you at the hospital?

Were x-rays or other scans performed? Yes No

What type of scans?

Were the scans positive or negative? What did they show about your condition?

Please describe, in your own words, how you were injured in this collision:

Please describe what events that happened in the collision that may have caused your injuries, i.e. I struck my head on the steering wheel:

Where did you receive follow-up treatment?

Treatment Provider 1:

Address:

Date of treatment:

to:

Treatment Provider 2:

Address:

Date of treatment:

to:

Pharmacy Information

Name*

Address*

Prior Accidents Or Injury

Have you ever been injured in the same area of your body before this collision?
Yes
No

When did those previous injuries occur?

What type of claim was it? (auto collision, workers’ comp?)

Have you ever had medical treatment for any previous injuries, from any source? Yes No

If so, when and where?

Have you ever filed a claim or lawsuit because of a previous injury case? Yes No

If so, when?

What was the result of that claim/lawsuit?

Have you ever had a serious illness? Yes No

What illness?

Insurance Information - Other Driver

Who was the other driver?

What is their address?

Please describe the vehicle they were driving - make, model, color:

What company is the other driver insured by?

What is their policy number?

What is their phone number?

Where is the other driver's vehicle now?

What is their address

Did you have an opportunity to take any photos of the vehicles on the scene? If so,please attach those photos here:

Insurance Information - Your Auto Insurance

Who is the owner of the vehicle you were driving?

What is their relationship to you?

Phone?

Address:

What company insures this vehicle?

What is their address/phone number?

Policy Number?

Liability Policy Limits?

Do you have Med-Pay coverage? Yes No

If so, how much?

Does this policy have Uninsured Motorist Coverage? If so, how much?

Do you have an automobile insurance policy (if different than above?)
Yes
No

What car? (Please describe)

What insurance carrier?

Address:

Policy Number:

Policy Limits:

Med-Pay Amount?

Uninsured Coverage?

Are there other household Automobile Insurance Policies?
Yes
No

Vehicle description:

Name of Insurance Carrier:

Address/Phone:

Policy Number:

Policy Limits:

Med Pay? Amount?

Uninsured coverage?

Your Health Insurance Information

Name of Health Insurance Company:

Phone Number:

Group Number:

Policy Number:

PPO?

HMO?

ERISA?

Medicare?

Medicare Number:

Medicaid?

Medicaid Number:

Address:

Prior Medical Providers and Hospitalizations:

Treatment Provider 1:

Dates Of Treatment:

Reason For Treatment:

Address:

Treatment Provider 2:

Dates Of Treatment:

Reason For Treatment:

Address:

Confidentiality Note: The information contained in this questionnaire is legally privileged and confidential information intended only for the use of the individual or entity named above. If the reader of the message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of the message is strictly prohibited.