Scene Investigation Intake Form

Scene Investigation Intake Form
Claim Number:
Description:
Client Information:
Clients Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Company:
Assigned Contact:
Incident Information:
Place of Incident:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time:
Location of incident:
Weather Conditions:
Was/Is the subject employed at location?
Was the incident reported when it occured?
Type of Injury:
Description of Injury:
Was treatment given?
Was the injured taken to a medical facility?
(If yes, where was the injured taken)
Was the incident site inspected?
Does the injured use a walker, cane, etc.?
What time did the inspection occur?
Was the injured taking any medications?
Who conducted the inspection?
Were photographs taken at the scene?
Claimants Info:
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender:
Height:
Weight:
Hair/Eye Color:
SSN:
Vehicle Info:
(Year, Color, Make, Model, License)
Does the injured wear glasses?
(If so, were they wearing their glasses that day)
Upload a photo/license/ID:

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NOTE: Please include a copy of the daily floor check log for the date of the accident (if applicable). Also, please upload any additional paperwork.
Assignment Details:
Should be Empty:

Scene Investigation Intake Form

Client Information:

Incident Information:

Claimants Info: