Accident Intake Form - Brief
What is your name?
Street Address Line 2
State / Province
Postal / Zip Code
Date of incident/Accident
Date Picker Icon
Time of incident/Accident
Where did the Incident happen?
How many vehicles were invovled?
How did the incident happen?
Were you the driver or a passenger? Who else was in the car with you?
In your opinion, who was at fault for causing the accident and damages, why?
How fast were you going at the time of impact?
Were you on your cell phone?
Talking, Texting, Looking down at it?
Had you been drinking any kind of Alcoholic Beverage?
Were Police called, did they respond?
What was the law enforcement agency or police department?
For example, DPS, Austin Police Department, Travis Co. Sheriff
What is the Police Report Number?
Did anyone get a ticket?
Were there any witnesses, if so, what are their names and contact information?
What conversations did you have with the other driver or witnesses, or Police?
Did you or the other driver make any admissions/admit fault for causing the accident?
What bodily injuries occurred?
list all injured body parts. Ex. head, right knee, lower back
Prior to the accident, did you ever see a doctor about any of those areas?
Any preexisting injuries
Did you go in the ambulance to the hospital?
How many days after the accident before you went to the Doctor or Medical Treatment Professional?
Was there a GAP in care from the accident date before you saw a doctor?
What medical treatment did you seek ?
What medical facilities and doctors did you see?
Are you willing to get MRI's on all injured body parts?
YES or NO
Do you have any numbness, tingling, headaches, blurred vision, mood swings, forgetfulness, brain fog or mental anxiety?
Possible need to see a neurologist.
How do you feel today?
Did you miss any work, have you returned to work? Are there any lost wages to date?
Do you have any insurance that may relate to this claim, such as, health insurance, auto insurance, homeowner's insurance or uninsured motorist?
Do you have Uninsured or Underinsured Motorists Coverage with your Car Insurance?
Yes and $ Policy Limits, or No
Do you live with anyone that you are related to that has a separate Auto Insurance Policy with Uninsured or Underinsured Motorists Coverage?
We may be able to stack additional insurance policies limits in some situations.
Do you have MEDICAID OR MEDICARE?
Have you contacted any of the above insurance companies? if so, what are the names and contact information?
claim number or contact information for the person you spoke with.
Have you been contacted by the Insurance Adjuster? if so, what is their name and contact information?
How badly was your car damaged?
totaled, exstensive or minor damages to certain part of car
Have you gotten your car fixed? Do you have transportation for medical appointments?
Have you contacted any other attorneys about this same case?
How were you referred to our office?
Referral name, website, Google search, etc...
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