Accident History Questionnaire
Your Name
Todays Date
-
Month
-
Day
Year
Date
Your Auto Insurance Company
Claim Number
If applicable, Adjuster's Name
Adjuster's Phone Number
Format: (000) 000-0000.
Your Health Insurance Company
Your Health Ins Member #
About Your Accident:
Date of Accident:
-
Month
-
Day
Year
Date
Time of Accident:
Hour Minutes
AM
PM
AM/PM Option
State accident occurred in?
Driver of car?
Owner of car?
Year and model of car?
Where were you seated?
Driver
Front passenger
Rear passenger
Did you see accident coming?
Yes
No
Was your car breaking?
Yes
No
Did you Brace for Impact?
Yes
No
Did the police come to the accident site?
Yes
No
Was a police report filed?
Yes
No
Your seat belt was:
On
Off
Does your vehicle have airbags?
Yes
No
Did airbags inflate?
Yes
No
Did any part of your body strike anything in the car?
Yes
No
If yes, please explain:
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What was your approximate speed?
What was their approximate speed?
Type of accident? Head on collision/ Broad-side collision/ Rear-End collision/ Front Impact
Approximate damage to your car $
Illustrate how accident happened:
After Your Accident
Where you able to get out of your car and walk unaided? Yes/No
Yes
No
Did you lose consciousness during your accident? Yes / No
Yes
No
Could you move all parts of your body? Yes/No
Yes
No
If no, what parts couldn't you move and why?
Describe how you felt later that day:
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Describe how you feel now:
What symptoms are you experiencing as a result of this accident?
Dizziness
Difficulty sleeping
Jaw/TMJ problems
Nausea
Memory loss
Arm/shoulder pain
Back pain
Headache(s)
Neck stiffness
Numb hands/fingers
Lower back pain
Blurred vision
Fatigue
Chest pain
Back stiffness
Buzzing in the ear
Tension
Short of breath
Leg pain
Ringing in the ear
Neck pain
Stomach upset
Numb feet/toes
Have you gone to a Hospital or seen any other Doctors?
Yes
No
When did you go?
Just after the accident
Next day
2 or more days later
How did you get there?
Ambulance
Private transportation
Doctor's name?
What kind of treatment did you receive?
Were X-rays taken?
Yes
No
Was medication prescribed?
Yes
No
Have you missed work?
Yes
No
If yes, from
to
Occupation?
Do you have an attorney for this claim?
Yes
No
If yes, Attorney's Name
Attorney's Phone Number
Format: (000) 000-0000.
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UNDERSTANDING PIP BENEFITS- MOTOR VEHICLE ACCIDENTS
In Massachusetts we have no fault benefits when it comes to injuries sustained in an automobile accident. This means that YOUR auto insurance company pays for your medical bills even when the accident is the other driver's fault. Most insurance policies carry Personal Injury Protection (PIP) benefits which will cover your initial $2000 of medical expenses. This includes transportation by ambulance, emergency room assessment, diagnostic testing and doctor's visits. These charges are paid at 100% by your insurance company- with no cost to you. We will ask you for your PIP information and file your claims directly to your auto insurance carrier.
If your injuries result in the need for care exceeding $2000 you will receive a formal PIP exhaustion letter from your auto carrier. This letter will be forwarded to your health insurance carrier to let them know you were injured in a motor vehicle accident and have been receiving treatment. Your health insurance carrier will then be responsible for processing and paying your claims under the terms of your normal health insurance coverage. This may include deductibles, co payments and limitations in covered services. We will file your claims directly to your health insurance carrier.
If there is a remainder balance due after your health insurance carrier processes and pays your claim, we will forward you a bill. You will be asked to pay the bill, and we will give you a receipt. You can forward this receipt to your auto insurance carrier and they will reimburse you for any out of pocket expenses related to treatment of accident related injuries. We do not forward remainder balances back to your auto insurance carrier for coordination of benefits once PIP is exhausted.
If you sustain injuries which result in medical expenses exceeding $2000 you have the option to pursue filing a law suit against the at fault party and their insurance company. In most cases that will require the use of an attorney. With your permission, we will forward all of your office notes along with your bills to your attorney so they can have a record of your treatment and expenses. It is important to understand that treatment under a PIP claim is solely for the treatment of injuries sustained as a direct result of your accident. It is the responsibility of the auto insurance company to return you to your pre accident state of health and functioning. Once you have reached that status, as determined by Dr. Robichaud, you will be discharged from treatment under your PIP claim. You can continue to receive treatment here in the future on an as needed basis under your normal health insurance coverage.
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