Car/Truck Accident Intake Form

Intake Form

Car/Truck Accident
Client Information
Full Legal Name*

First NameLast Name
Email Address*
example@example.com
PHONE NUMBER

Cell phone is preferred. By providing your cell phone number, you are giving us permission to contact you via text message.
Area Code*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Information
Marital Status:

SingleMarriedDivorcedWidow
Date of Birth

MonthDayYear
Date
Spouse's Name/Significant Other

First NameLast Name
Children's Names/Ages
Prior Criminal Record:

YesNo
If yes, please explain.
Accident Information
Date & Time of Accident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Street Name Where Crash Occurred
Nearest Cross Street
City*
County
How did the accident happen?
Passengers in Vehicle
Investigated by Police?

YesNo
Report Number
Statements given?

YesNo
If yes, to whom?

First NameLast Name
Injuries
Injuries Sustained in this Accident*
Prior Injuries
Additional Information Relating to your Injuries or Health
YOUR Insurance Information

We will not contact your insurance company without your permission and/or unless we represent you.
Insurance Company
Policy Number
Under/Uninsured Coverage?

YesNo
If yes, coverage limits?
Medical Payment Coverage?

YesNo
If yes, coverage limits?
Your Health Insurance Information
Insurance Company
Policy Number
Group Number
Identification Number
Type of Coverage
e.g. PPO or HMO
Medicare?

YesNo
Medicare Number
Medicaid?

YesNo
Medicaid Number
Medical Treatment Information
Ambulance?

YesNo
Name of Ambulance Service
Emergency Room?

YesNo
Name of Emergency Room
Treating Physician
Property Damage Information
Is the property damage claim resolved?

YesNo
Do you have an estimate for property damage or value of your total loss vehicle?

YesNo
Do you have pictures of your vehicle?

YesNo
Lost Wages
Did you miss work as a result of this accident?

YesNo
If yes, please fill out the following information about your employment:

Employer NameJob Title
Estimate of lost wages:
Rate of Pay
Paid how often?
e.g. yearly, monthly, bi-weekly, weekly, hourly
Defendant's Insurance Information
File Upload - if you are uploading an Illinois Traffic Crash Report or a Driver Information Exchange you can skip this section.

Cancelof
Defendant's Insurance Company
Policy Number
Defendant's Full Legal Name*

First NameLast Name
Defendant's Insurance Info.

This is information that is not on the Illinois Traffic Crash Report or Driver Information Exchange
Defendant's Insurance Claim Number
Bodily Injury Adjuster's Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Property Adjuster's Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
How did you find us?*
e.g. Google, Avvo, Facebook, Yelp, Friend's Name, Attorney Referral Name, etc.
Any Additional Notes or Information
Should be Empty:

Intake Form

Client Information

Personal Information

Accident Information

Injuries

YOUR Insurance Information

Your Health Insurance Information

Medical Treatment Information

Property Damage Information

Lost Wages

Defendant's Insurance Information

Defendant's Insurance Info.