ACCIDENT QUESTIONNAIRE
Winston-Salem
3570 Vest Mill Road,
#B • Winston-Salem, NC 27103
QUESTIONS ABOUT ACCIDENT
Date of Accident
Hour
Specific location of accident?
2.Describe in detail, in your own words, how the accident happened?
3.In the accident were you the o Driver o Passenger o Pedestrian o Other
4.Did your vehicle strike the other vehicle? o Yes o No
5.Did the other vehicle strike your car? o Yes o No
6.Were you struck from? o Behind o Front o Driver Side o Passenger Side
7.Who were traffic citations issued to? o You o Driver of Your Vehicle o Driver of the Other Vehicle o No Citations Given
8.Were police officers at the scene yes/ no
9.Were you aware of the impending crash? o Yes o No
10. Head Position at time of impact? o Forward o Left o Right o Up o Down
11.Did your body hit anything? o Yes o No If Yes, describe
12.Did air bag deploy? o Yes o No If yes, were you struck by air bag? o Yes o No Were you burned? o Yes o No
13. Were you wearing a hat or eye or sunglasses? o Yes o NoIf yes, were they still on after crash? o Yes o No
14. Did you lose consciousness o Yes o No If Yes, for how long
15. Estimated damage to the vehicle you were in? Amount of damage
16.Your speed at time of accident
17.Road Conditions o Dry o Damp o Wet o Snow o Ice o Other
18. Was the at fault driver intoxicated or under the influence of drugs? o Yes o No
Adjuster handling your bodily injury claim
Claim #
If you do not know the claim number do you have their Policy Number
Adjuster Phone Number
Adjuster Fax Number
Attorney Name
Legal Assistant
Address
Phone
Fax
Patient Signature
AT FAULT
(Person who caused the accident insurance company)
ATTORNEY INFORMATION (If Applicable)
Date
/
Month
/
Day
Year
Date
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