Accident Smarts: Accident Assessment

1
Name* This field is required.
First Name
Last Name
2
Type of accident you were in:* This field is required.
Car/Motorcycle
Bicycle/Pedestrian
Dog Bite
Accident at Work
3
State my accident happened in:
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4
_________ paid to fix or replace my car.* This field is required.
My Insurance
Other Insurance
Myself
Not done yet
Can’t afford to / Didn’t know who should
Other
5
I went to _______ for medical care after my accident.* This field is required.Select all that apply:
Urgent Care
Emergency Room
Family Doctor
Physical Therapy / Chiropractor
Can't afford to / Didn't know I should
Haven't seen a doctor
Other
6
Who paid for your time off of work after the accident?* This field is required.
Company PTO
Insurance
Didn’t get paid
Can’t afford to / Didn’t miss work
Not Applicable
Other
7
So far, have you paid out of pocket for expenses related to your accident? Our objective is to ensure you don't pay for anything related to your accident and recoup the money if you have. Ex: Rental Car, Ambulance Bill, Co-Pays, Towing Bill, etc.
YESNO
8
What do YOU think insurance should pay for after your accident?Select all that apply
Full cost to fix or replace vehicle
Rental car
Other transportation: Uber, Lyft, etc.
Time off of work
All medical bills
Future medical costs
Recovery time
Inconveniences to your life
9
What do YOU think insurance should pay for after your accident?Select all that apply
Time off of work
All medical bills
Future medical costs
Recovery time
Inconveniences to your life
Help at home
Time spent in the process
10
Insurance is responsible to pay ALL costs & burdens that result from your accident.If you're not properly paid for your accident, who is?
11
We can help! Get Accident Smart with us and know the truth that insurance companies hide from you.As experts in the accident process, we know you deserve better!
12
How should Accident Smarts connect with you about your accident?* This field is required.All communication is confidential and always free
Call
Text
Email
Book a Virtual Conversation
13
Enter preferred call/text number* This field is required.
Please enter a valid phone number.
14
Enter preferred email used* This field is required.
example@example.com
15
Book a Virtual ConversationSelect a time that fits your schedule
Should be Empty: