brookevillechiropractic.com - TIPP AUTOMOBILE ACCIDENT HISTORY FORM

Your Name:

Today’s Date:

Date

Your auto insurance information:

Insurance company:

Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Agent/Adjusters Name:

Claim #:

Attorney’s Name:

Phone:

Please enter a valid phone number.Format: (000) 000-0000.

The At Fault’s Auto insurance information:

Insurance Company:

Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Agent/Adjuster’s Name:

Claim #:

Date of Accident:

Date

Time of Accident:

am/pm

City & Street of Accident:

WETDRYICYOTHER

YesNo

If yes, what is the name and city of the hospital?

How did you get to the hospital?

What parts of your body were x-rayed at the hospital?

What did the hospital do for your injuries?

How long did you stay at the hospital?

What bleeding cuts did you sustain during this accident?

What bruises did you sustain during this accident?

Where were you seated in the vehicle?

AWARESURPRISE

YESNO

How long?

Did you experience a flash of light or explosion in your head?

If you still have some of those symptoms, which ones?

How far is the top of the headrest or seatback from the top of your head (approximately)?

Inches ABOVE or BELOW

YESNO

If yes, was it a lap seatbelt_____ or shoulder-lap seatbelt

List the year, make and model of the vehicle you were in: (Year, make and model)

YESNO

If no, then estimate the speed of the vehicle you were in:

mph

Slowing downGaining speedTraveling at a steady rate of speed

YESNO

If YES, then describe:

What is the estimated cost damage to the vehicle you were in?

$

YESNO

If no, how was it turned?

YESNO

If no, what direction was it turned and by how much?

What is the year, make and model of the other vehicle?(Year, make and model)

YESNO

If yes, what was its approximate speed?

Mph

Slowing downGaining speedTraveling at a steady speed

Please describe, to the best of your knowledge, what happened during this accident:

AUTOMOBILE ACCIDENT HISTORY FORM

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