Name
*
First Name
Last Name
Today's Date
*
/
Month
/
Day
Year
Date
Motor Vehicle Accident (MVA) Questionnaire
Please fill this out to the best of your ability!
Date of Accident
*
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Month
-
Day
Year
Date
What state did the accident occur in?
*
Were you the driver or a passenger?
*
Where in the car were you?
*
Where were you looking? Did you see it coming?
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Did you hit your head? Or lose consciousness?
*
What part of the car was hit?
*
Was anyone else in the car? How are they?
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Were you wearing your seatbelt?
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Yes
No
What kind of car were you in?
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What kind of car hit you?
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How fast were you going?
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How fast were they going?
*
Did the airbags deploy in either car? Which ones?
*
How much damage to your car? Was it totaled?
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How much damage to the other car? Was it totaled?
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When did the pain start? (Immediately, later that day, etc.)
*
Did you seek medical care at the time of the accident?
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Yes
No
If yes, where did you go?
Did they do any imaging? (X ray, MRI, CT, etc.)
What type of treatment did you receive? (ice, medication, etc.)
Please explain any other treatment you received for injuries sustained in the accident
*
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Auto Insurance Carrier
*
Claim Number
*
Agent Contact Name
*
Insurance Agent Phone Number
*
Do you have medical payments on your policy (MedPay)?
*
Yes
No
If yes to MedPay, what is the amount? *Please call your auto insurance carrier directly to check*
Attorney Name/Practice
Attorney Phone Number
Submit
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