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
January
February
March
April
May
June
July
August
September
October
November
December
Month
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Day
2022
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1925
1924
1923
1922
1921
1920
Year
Date Of Incident
-
Month
-
Day
Year
Date
Time of Incident
State of Incident
Please Select
California
Arizona
The client was the
Please Select
Driver
Passenger
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Marital Status
Please Select
Married
Single
Fiance
Partner
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?
Please Select
Yes
No
Do you have uninsured/underinsured motorist coverage?
Please Select
Yes
No
Not Sure
Do you have medical payments coverage (Medpay)?
Please Select
Yes
No
Not Sure
Is your car drivable?
Please Select
Yes
No
Was your vehicle towed?
Please Select
Yes
No
If it was towed to a tow yard, which location?
Where is your vehicle now?
Did you take photos?
Please Select
Yes
No
Upload Photos (Include your Car Damage, bodily damage, if any, Driver License and Insurance Cards as well as the other driver’s)
Browse Files
Drag and drop files here
Choose a file
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?
Please Select
Yes
No
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?
Please Select
Yes
No
Workers Compensation Claim?
Please Select
Yes
No
Did you suspect driver impairment?
Please Select
On Cell Phone
Intoxicated
Medical
Other
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?
Please Select
Yes
No
Which Department were they from?
Police report or event number?
Was Anyone Cited at the accident?
Please Select
Yes, I was cited
No, the other driver was cited
Both parties
Did you provide a statement to your insurance company?
Please Select
Yes
No
Were there any WITNESSES to the crash?
Please Select
Yes
No
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?
Please Select
Yes
No
If yes, which one?
Did you go by ambulance?
Please Select
Yes
No
If yes, which one?
Did you see your primary care provider for your injuries ?
Please Select
Yes
No
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?
Please Select
Yes
No
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
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