Auto Accident Intake Form

Auto Accident Intake Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date Of Accident*

MonthDayYear
Date
Time of The Accident*

Hour Minutes

AM/PM Option
Name of YOUR Car Insurance: *
Claim Number: *
Attorney's Name

First NameLast Name
Attorney's Phone Number
Please enter a valid phone number.
Attorney's Email (if applicable)
example@example.com
Please Describe how the collision happened:
Were you wearing a seatbelt? *
What type of Seatbelt?*

Lap BeltShoulder BeltBothNone
What was your position in the car?*

DriverFront PassengerLeft RearRight rear
If the Driver, were your hands on the steering wheel?

BothLeftRightNone
Direction of Impact*

FrontBackLeftRightOther
If Other, what was the direction of Impact:
What was the year, make and model of your car? *
What was the approximate speed of YOUR vehicle when the accident occurred? *
What was the year, make and model of the other car? *
What was the approximate speed of the OTHER vehicle when the accident occurred? *
Did the Airbags Deploy?*

YesNo
Were you rendered unconscious at the time of the accident?*

YesNo
Did you strike another vehicle?*

YesNo
Did another vehicle strike your vehicle?*

YesNo
If 2nd Collision- Angle of second Impact:

FrontBackLeftRightOther
If other, Please explain:
In relation to the headrest, was your headrest set:*

LowMiddleHighI don't know
Where was your head facing at the time of impact?

Straight Ahead?LeftRightBenhindInclinded
Were you surprised by the impact?*

YesNo
If no, How did you brace?

With handsWith feet
Were you leaning forward at the time of the accident?*

YesNo
Did your seat break or bend?*

YesNo
Did you feel pain immediately after the accident?*

YesNo
If yes, where?
Did you strike anything in the vehicle at the time of impact?*

NoSteering WheelDashboardLeft Side DoorLeft Side WindowWindsheildRoofRight Side DoorRight Window
Which part of your body Struck the area of the car?*

HeadChestChinShoulderKneeBackFootLegNoneOther
Immediately After the accident how did you feel? (Click all that apply)*

DizzyDazedWeakUpsetDisorientedNervousNauseousNone of theseOther
If other please explain:
Police and Ambulance:
Was the Accident report to the police?*

YesNo
Were traffic citations issued?*

YesNo
If yes, To whom?
Did you go to the hospital?*

YesNo
If yes, when?
If yes, How did you get there?

AmbulancePolice CarPrivate Transportation
Were you Admitted to the hospital?*

YesNo
If yes, For how long?
Name Of the Hospital?
Name of the Doctor that treated you:
Treatment Given (Check all that apply)*

NoneX-RaysPain MedicationStitchesMuscle RelaxantsBandagedCervical CollarPhysical TherapyInstructions Regarding ConcussionInstructed Regarding Sprains and StrainsInstructed to call an OrthhopedistInstructed to call a private physicianReferred to this officeOther
What other doctors have you seen as a result of this injury?*
Please Sign*

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Today's Date

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Date
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Auto Accident Intake Form

Police and Ambulance: