Accident Injury Intake Form Name * First Name Last Name Today's Date MM DD YYYY Email * Date of Accident MM DD YYYY Please describe the accident in as much detail as possible below. Was anyone else in the vehicle with you? If yes, please list number of people and names. Where were you seated? Front seat DRIVER Front seat PASSENGER Rear seat behind DRIVER Rear seat behind PASSENGER Name of driver. If not self: Name of driver of other vehicle. Did airbags deploy? Yes No Did Police arrive? Yes No Were you using a seatbelt? Yes No Did you strike the windshield or objects in the car? Yes No If so, please name the objects below. Were you knocked unconscious? Yes No Where was your vehicle impacted? Front Rear Passenger Side Driver's Side YOUR Auto Insurance Company. YOUR Auto Insurance Company Policy Number. YOUR Auto Insurance Company Claim Number. YOUR Auto Insurance Company Phone Number. OTHER'S Auto Insurance Company Name. OTHER'S Auto Insurance Company Policy Number. OTHER'S Auto Insurance Company Claim Number. OTHER'S Auto Insurance Company Phone Number. Did you feel pain immediately after the accident? Yes No Later that day Next day More than a day later Were you taken any where after the accident? If yes, please describe where, how, and did you receive treatment. Are your work or activities of daily living restricted as a result of this accident/injury? If yes, how? Have you missed any work because of this accident/injury? Have you retained an attorney? If yes, please list name and number below. Thank you! We look forward to serving you!
