Auto Accident Intake Form
Today's Date
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Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date Of Accident
*
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Month
-
Day
Year
Date
Time of The Accident
*
Hour Minutes
AM
PM
AM/PM Option
Name of YOUR Car Insurance:
*
Claim Number:
*
Attorney's Name
First Name
Last Name
Attorney's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Attorney's Email (if applicable)
example@example.com
Please Describe how the collision happened:
Were you wearing a seatbelt?
*
Please Select
Yes
No
What type of Seatbelt?
*
Lap Belt
Shoulder Belt
Both
None
What was your position in the car?
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Driver
Front Passenger
Left Rear
Right rear
If the Driver, were your hands on the steering wheel?
Both
Left
Right
None
Direction of Impact
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Front
Back
Left
Right
Other
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?
*
Yes
No
Were you rendered unconscious at the time of the accident?
*
Yes
No
Did you strike another vehicle?
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Yes
No
Did another vehicle strike your vehicle?
*
Yes
No
If 2nd Collision- Angle of second Impact:
Front
Back
Left
Right
Other
If other, Please explain:
In relation to the headrest, was your headrest set:
*
Low
Middle
High
I don't know
Where was your head facing at the time of impact?
Straight Ahead?
Left
Right
Benhind
Inclinded
Were you surprised by the impact?
*
Yes
No
If no, How did you brace?
With hands
With feet
Were you leaning forward at the time of the accident?
*
Yes
No
Did your seat break or bend?
*
Yes
No
Did you feel pain immediately after the accident?
*
Yes
No
If yes, where?
Did you strike anything in the vehicle at the time of impact?
*
No
Steering Wheel
Dashboard
Left Side Door
Left Side Window
Windsheild
Roof
Right Side Door
Right Window
Which part of your body Struck the area of the car?
*
Head
Chest
Chin
Shoulder
Knee
Back
Foot
Leg
None
Other
Immediately After the accident how did you feel? (Click all that apply)
*
Dizzy
Dazed
Weak
Upset
Disoriented
Nervous
Nauseous
None of these
Other
If other please explain:
Police and Ambulance:
Was the Accident report to the police?
*
Yes
No
Were traffic citations issued?
*
Yes
No
If yes, To whom?
Did you go to the hospital?
*
Yes
No
If yes, when?
If yes, How did you get there?
Ambulance
Police Car
Private Transportation
Were you Admitted to the hospital?
*
Yes
No
If yes, For how long?
Name Of the Hospital?
Name of the Doctor that treated you:
Treatment Given (Check all that apply)
*
None
X-Rays
Pain Medication
Stitches
Muscle Relaxants
Bandaged
Cervical Collar
Physical Therapy
Instructions Regarding Concussion
Instructed Regarding Sprains and Strains
Instructed to call an Orthhopedist
Instructed to call a private physician
Referred to this office
Other
What other doctors have you seen as a result of this injury?
*
Please Sign
*
Today's Date
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Month
-
Day
Year
Date
Submit
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