Accident/Injury Form
Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Date and Time of Accident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Were you:
*
Driver
Passenger
Pedestrian
Were there any other passengers in your vehicle at the time of accident?
*
Yes
No
Make/model of your vehicle?
*
Make/model of other vehicle?
*
Were you struck from:
*
Behind
Right Side
Left Side
Front
Parked
Did your car strike the others involved?
*
Yes
No
Undetermined
Did the other car strike yours?
*
Yes
No
Undetermined
The driving conditions were:
*
Clean & Dry
Wet
Icy
Foggy
Dark
Did you see the accident about to occur?
*
Yes
No
Were you able to brace yourself?
*
Yes
No
As a result of the accident, were traffic citations issued to you?
*
Yes
No
Were you wearing your seatbelt at the time of accident?
*
Yes
No
Did the seatbelt engage?
*
Yes
No
How fast was your vehicle moving at the time of impact?
*
Other vehicle?
*
In relation to your head, where was the headrest positioned?
*
Above
Below
Level With
Did the front airbags deploy?
*
Yes
No
Did the side airbags deploy?
*
Yes
No
Did the rear airbags deploy?
*
Yes
No
Which direction were you facing at the point of impact?
*
Left
Right
Straight Ahead
Looking Down
Did your body strike any part of the interior?
*
Yes
No
If yes, what did you strike?
Was there damage to either vehicle?
*
Yes
No
Value of damage to your vehicle?
*
Value of damage to their vehicle?
*
Was your vehicle drivable following the accident?
*
Yes
No
Were you evaluated at the scene of the accident?
*
Yes
No
Were you transported?
*
Yes
No
If yes, where and by whom?
Where did you go following the accident?
*
How did you arrive there?
*
Drove self
Other
If other, please specify
Have you received treatment from any other healthcare provider for current symptoms?
*
Yes
No
Back
Next
Check Symptoms You Have Noticed Since The Accident
*
Headache
Neck Pain
Neck Stiffness
Dizziness
Back Pain
Nervousness
Tension
Irritability
Chest Pain
Sleeping Problems
Head Too Heavy
Pins & Needles in Arms
Pins & Needles in Legs
Numbness in Fingers
Numbness in Toes
Shortness of Breath
Fatigue
Depression
Lights Bother Eyes
Loss of Memory
Ears Ringing
Face Flushed
Buzzing in Ears
Loss of Balance
Fainting
Loss of Smell
Loss of Taste
Diarrhea
Feet Cold
Hands Cold
Stomach Upset
Constipation
Cold Sweats
Fever
Other
Did you require post-accident hospitalization?
*
Yes
No
If yes, where and for how long?
Have you lost any days of work?
*
Yes
No
If yes, how many and through what date?
Back
Next
Insurance Information
Your Insurance Company
*
Have you been contacted by an insurance adjustor regarding this claim?
*
Yes
No
If yes, name of adjustor?
And adjustor's phone?
If you were assigned a medical claim number, please enter it here.
Do you have an attorney that has advised you in this case?
*
Yes
No
If yes, attorney’s name?
Law Firm?
Submit
Should be Empty: