Digital Intake Form

Digital Intake Form

Please fill out the form to the best of your ability
Full Name

First Name Middle Name Last Name
LAWFIRM / ATTORNEY
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date

Month Day Year
Date Of Incident

Month Day Year
Date
Time of Incident
State of Incident
The client was the
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Marital Status
If Married, please provide your spouse's name
Vehicle & Insurance Information
Year/Make/Model
State Registered
Claim Number & Adjuster Info
Who is your Car Insurance ?
Can you please provide your Declarations Page?
Do you have uninsured/underinsured motorist coverage?
Do you have medical payments coverage (Medpay)?
Is your car drivable?
Was your vehicle towed?
If it was towed to a tow yard, which location?
Where is your vehicle now?
Did you take photos?
Upload Photos (Include your Car Damage, bodily damage, if any, Driver License and Insurance Cards as well as the other driver’s)

Cancel of
We will now collect your information about the accident.
Explain how the collision happened
Which city did the accident take place?
Which street(s) did the accident occur?
Did your airbags deploy?
How many people were in your car at the time of the accident?
List names of Minor Children in Vehicle
How many people were injured?
Where were you driving to/from?
At the time of the incident, were you using your vehicle for work purposes?
Workers Compensation Claim?
Did you suspect driver impairment?
Please explain the impairment.
Did the other driver say anything to you? Admit it was their fault? If so, what was said?
Did the police come?
Which Department were they from?
Police report or event number?
Was Anyone Cited at the accident?
Did you provide a statement to your insurance company?
Were there any WITNESSES to the crash?
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
We want to be sure to document any and all bodily injuries you may have sustained because of the accident.
Did you go to the hospital/urgent care?
If yes, which one?
Did you go by ambulance?
If yes, which one?
Did you see your primary care provider for your injuries ?
What is the name and phone number of your primary care doctor for the last 5 years?
Who is your Health Insurance Carrier?
What symptoms do you have since the crash? Check all that apply

Headaches Dizziness Nausea/Vomiting Rining in Ears Sensitivity to light/sound Jaw pain Taste of blood in mouth Neck pain Shoulder pain Elbow pain Finger pain Hand pain Chest Pain Upper Back pain Mid Back pain Lower Back pain Abdominal pain Hip pain Leg pain Ankle pain Knee pain Feet pain Loss of consciousness (LOC) None Other
When did you start feeling pain?
Have you had any prior injuries to the body parts of which you are injured now?
If yes, please indicate which body parts
What is your weekly availability for medical treatments?
In the last 10 years, have you been in any prior car crashes, slip/falls, workers comp cases, dog bites for which you made a claim for, or received a settlement for?
Please state Date of incident

Month Day Year
Date
Type of Incident
This form was created inside of Terry Consultants.
Should be Empty:

Digital Intake Form

Vehicle & Insurance Information

We will now collect your information about the accident.

We want to be sure to document any and all bodily injuries you may have sustained because of the accident.

In the last 10 years, have you been in any prior car crashes, slip/falls, workers comp cases, dog bites for which you made a claim for, or received a settlement for?

This form was created inside of Terry Consultants.