Auto Accident Comprehensive Questionnaire

Auto Accident Client Questionnaire

Thank you for trusting us with your case. These questions help us build the strongest possible claim for you. You can leave questions blank if you don't feel comfortable answering.
About you
Full name

First NameMiddle NameLast Name
Email
example@example.com
Best phone number
Please enter a valid phone number.Format: (000) 000-0000.
Date of the collision

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Anyone we have permission to speak with about the case
How you found us
How did you first hear about us?
If someone referred you, who was it?
Are you currently treating with a chiropractor?
How it happened
It helps to include: • The date and roughly what time it was • Where you were coming from and heading to • The street or intersection, and which direction you were traveling • Weather, lighting, and road conditions • Roughly how fast you were going • What you saw the other vehicle do • Where your vehicle was hit, and where it ended up If anything is fuzzy, just say so — "I don't remember" is a perfectly good answer.
Describe how the collision happened
Take your time — the more detail, the better.
What happened at the scene afterward? Who did you speak with?
Did anyone apologize or admit fault?
What, if anything, is wrong or missing in the police report?
Other driver behavior you noticed

Something else
Were you wearing a seatbelt?
Did the airbags deploy?
Did you go to the hospital from the scene?
Other people who may be responsible
Was anyone driving for a company at the time?
Did road or roadway conditions seem to play a part?
Did anything about the vehicle seem to fail?
Do you have any reason to believe any driver had been drinking or using drugs?
If yes, where had the driver been beforehand?
A bar, restaurant, party, or event — a guess is fine.
Was the other driver the owner of the car?
Evidence
What evidence do you already have?
Upload any evidence you have not already shared

Cancelof
Were there any cameras nearby?
Where is the vehicle now?
Did anyone ask you to release the vehicle or approve repairs?
Do you still have any items from the crash?
Any other witnesses or people who know what happened?
Who was with you
Who else was in the vehicle with you?
Your treatment
Where have you been treated so far?

Somewhere else
For each place, name the location and roughly when you first went
Has a doctor recommended treatment you haven’t been able to start?
Please check everything, even things that seem small or started days later. It's far easier to include something now than to add it months from now.
What symptoms or injuries have you had since the collision?
Any symptoms or injuries not on that list?
Anything that hurts, feels off, or has changed
Did you black out, feel dazed, or have any memory gap?
When did your symptoms first start?
Are your symptoms getting better, worse, or staying about the same?
On a normal day, how much pain are you in?
What can you no longer do at work, at home, or for fun that you could do before?
Lifting your kids, sleeping, driving, exercising, hobbies
Has anyone had to help you with things you used to do yourself?
Were you pregnant at the time of the collision?
What is making it hard to get to appointments?
Have you ever injured the same body parts before?
If yes, roughly when and what happened?
Do you have any ongoing health conditions that the crash has made worse?
Insurance and coverage
These help us find every source of coverage that could pay for your treatment. “Not sure” is a completely normal answer — we can look most of this up.
Do you have MedPay coverage on your auto policy?
How many vehicles are at your address, and who owns each?
Does anyone you live with have their own auto insurance?
If yes, who are they and what company do they use?
What type of health coverage do you have?
Were you working or driving somewhere for work when the crash happened?
Has a workers’ compensation claim been filed?
Have you spoken with any insurance adjuster since the crash?
Since the crash, have any of these happened?
Your vehicle and bills
Is your vehicle drivable right now?
Do you currently have a way to get around?
Have you received any medical bills, invoices, or collection notices?
Work and income
Have you missed work because of the crash?
Which dates or how many days did you miss?
Were you paid for that time?
About how much money do you feel you have lost?
Where do you work and what do you do?
Are you having trouble doing your job or have you had to change your hours or duties?
Do you expect this to affect what you can earn going forward?
A few housekeeping questions
Have you spoken with or hired any other attorney about this crash?
Were you ticketed or charged with anything from this crash?
If yes, what is the ticket or charge, and what is the court date?
Have you posted about the crash or your injuries on social media?
Anything else
Is there anything else you want the firm to know that we haven’t asked about?
What worries you most about your case right now?
Agreement
Should be Empty:

Auto Accident Client Questionnaire

About you

How you found us

How it happened

Other people who may be responsible

Evidence

Who was with you

Your treatment

Insurance and coverage

Your vehicle and bills

Work and income

A few housekeeping questions

Anything else