ACCIDENT QUESTIONNAIRE

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

Format: (000) 000-0000.

Adjuster Fax Number

Attorney Name

Legal Assistant

Address

Phone

Format: (000) 000-0000.

Fax

Patient Signature

AT FAULT (Person who caused the accident insurance company)

ATTORNEY INFORMATION (If Applicable)

Date