• Accident/Injury Form

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date and Time of Accident*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Were you:*
  • Were there any other passengers in your vehicle at the time of accident?*
  • Were you struck from:*
  • Did your car strike the others involved?*
  • Did the other car strike yours?*
  • The driving conditions were:*
  • Did you see the accident about to occur?*
  • Were you able to brace yourself?*
  • As a result of the accident, were traffic citations issued to you?*
  • Were you wearing your seatbelt at the time of accident?*
  • Did the seatbelt engage?*
  • In relation to your head, where was the headrest positioned?*
  • Did the front airbags deploy?*
  • Did the side airbags deploy?*
  • Did the rear airbags deploy?*
  • Which direction were you facing at the point of impact?*
  • Did your body strike any part of the interior?*
  • Was there damage to either vehicle?*
  • Was your vehicle drivable following the accident?*
  • Were you evaluated at the scene of the accident?*
  • Were you transported?*
  • How did you arrive there?*
  • Have you received treatment from any other healthcare provider for current symptoms?*
  • Check Symptoms You Have Noticed Since The Accident*
  • Did you require post-accident hospitalization?*
  • Have you lost any days of work?*

  • Insurance Information

  • Have you been contacted by an insurance adjustor regarding this claim?*
  • Do you have an attorney that has advised you in this case?*
  • Should be Empty: