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Intake Form -Auto Accidents

Section 1 - Accident Information
I am responding to these questions in regard to:
1. Your role in the accident:
2. Number of vehicles involved in accident:
3. Vehicle description: Vehicle 1: (the one you were in, or that struck you if you were a pedestrian)


Vehicle 2:


Vehicle 3:


Date/Time of Accident
Location of Accident: City:

Street:
Crossing street:
Vehicle 1: (the one you were in, or that struck you if you were a pedestrian)
Road vehicle was on:
Direction of travel:
Movement of vehicle:
Vehicle 2:
Road vehicle was on:
Direction of travel:
Movement of vehicle:
Vehicle 3:
Road vehicle was on:
Direction of travel:
Movement of vehicle:
Please describe your accident:
Who do you believe to be at fault?
Why?
Were police called? Yes  No
Was anyone given a ticket? Yes  No
Who got the ticket and what was it for (if known)?
Were all drivers identified? Yes  No
Was the at-fault driver identified? Yes  No
Any indication drugs or alcohol were involved? Yes  No
By whom?
Any indication that any driver was driving in connection with their employment and/or for any governmental entity at the time of the accident? Yes  No

Section 2 - Losses (if known)
How much property damage was done:  
Vehicle 1 Describe:

Estimated Dollar Amount:
Was the vehicle totaled or repaired?
Who paid for the vehicle repair?

Vehicle 2 Describe:

Estimated Dollar Amount:
Was the vehicle totaled or repaired?

Vehicle 3 Describe:

Estimated Dollar Amount:
Was the vehicle totaled or repaired?

Have you incurred or will you incur damages for: Medical Expense? Yes  No
Amount if known

Lost wages? Yes  No
Amount if known
Time missed or expected to be missed

Personal Property? Yes  No  Amount
Describe:


Rental Car? Yes  No  Amount
Number of days:

Other: Yes  No  Amount

Describe:

Section 3 - Injuries
Were you or anyone involved in the accident injured? Yes  No  Who?
Did the accident involve death? Yes  No
Describe the injuries: Fracture:   
Cuts or bruising:   
Back pain:   
Neck pain:   
Headaches:   
Numbness/tingling:   
Knee:   
Shoulder:   
Hand:   
Wrist:   
Elbow:   
Jaw pain:   
Dental:   
Loss of consciousness:   
Memory Difficulties:   
Confused:   
Internal injuries:   
Have you had any previous or subsequent injuries to the areas of the body injured in this accident?No  Yes  Describe:  

Section 4 - Treatment Information - if known
I am in pain, but have not yet seen a doctor. Yes  No
Was an ambulance called? Yes  No
Did you go to the emergency room? Yes  No
How long were/have you been in the hospital?
Have you followed up with care for injuries caused by the accident? Yes  No

If so, with whom?
Family Physician
Chiropractor
Physical Medicine/Rehabilitation Doctor
Neurologist
Orthopedic Doctor
Surgeon
Psychologist/Psychiatrist
Dentist/TMJ specialist
Physical Therapist
Massage Therapist

Were there any diagnostic tests run? No  Yes  Results:

X-rays:
CT Scan:
EMG/NCV:
MRI:
Other:

Section 5 - Insurance Information - if known
Types of insurance you have: Health Insurance
Medicaid/Medicare
Military Medical Care
Are you eligible for Workman's Compensation benefits? Yes  No
Were you an employee injured while performing work-related duties? Yes  No  Not sure
Company insuring the vehicle of driver #: 1.   
2.   
3.   

If you did not own the vehicle you were in, did you have vehicle insurance in your own name covering you at the time of the accident?

No  Yes  Which company?
At the time of the accident, were you residing with a relative who had vehicle insurance in effect regardless of whether you were listed as an insured? No  Yes  Which company?

Additional Information / Issues, Concerns
Please submit any additional information that may help evaluate your claim. Also submit any issues or concerns you may have.

Contact Information
First Name*
Last Name*
Home Phone*
Work Phone*
Cell Phone*
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
Have you settled any claims that you may have stemming from this accident? No  Yes  
Are you currently represented by an attorney on this matter? Yes  No
Are you satisfied with the representation you are getting? Yes  No
How did you hear about this Web site?   
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
d. There can be no guarantee that Internet mail is fully secure or private. Please do not transmit confidential information. Transmission of information is not intended to and does not create an attorney-client relationship. Therefore, please do not assume that communications sent using electronic mail are privileged or confidential. Once we receive your information, we will follow up with you if we believe we could be of benefit to your case. Only once our attorneys agree to accept your case, in writing, will an attorney-client relationship exist.