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INTAKE REPORT AND INJURY STATEMENT
Email address *
ACCIDENT PHOTOS
property damage
scene
client
injuries
select:
index info:
date contract signed:
MM
/
DD
/
YYYY
investigator:
Your answer
source in/how did you hear about us:
Your answer
language:
engl
span
rus
select
date of accident: *
MM
/
DD
/
YYYY
CLIENT
first: *
Your answer
middle:
Your answer
last: *
Your answer
driver
passenger
rider
pedestrian
select one
ok to discuss with spouse:
yes
no
N/A
select one
spouse name:
Your answer
do you have kids:
yes
no
select
if yes, how many and age(s):
Your answer
CONTACT INFO:
street: *
Your answer
unit no.:
Your answer
city: *
Your answer
state: *
Your answer
zip: *
Your answer
phone 1: *
Your answer
text messages:
yes
no
select
phone 2:
Your answer
e-mail:
Your answer
date of birth: *
MM
/
DD
/
YYYY
social security no.:
000-00-0000
Your answer
driver license no.:
Your answer
EMERGENCY CONTACT:
full name: *
Your answer
relation to you:
Your answer
phone: *
Your answer
e-mail:
Your answer
CLIENT AUTO INSURANCE:
carrier: *
(if none - put N/A)
Your answer
policy no.: *
(if none - put N/A or unknown)
Your answer
claim no.: *
(If none - put N/A or unknown)
Your answer
collision coverage:
yes
no
N/A or unknown
select one
if yes, specify limits:
Your answer
rental coverage:
yes
no
N/A or unknown
select one
if yes, specify limits:
Your answer
MedPay:
no
yes
N/A or unknown
select one
if yes, specify limits:
Your answer
UM/UIM:
no
yes
N/A or unknown
select one
if yes, specify limits:
Your answer
claim adjuster:
(Your insurance adjuster)
first:
Your answer
last:
Your answer
claim adjuster contact:
tel.:
Your answer
fax:
Your answer
e-mail:
Your answer
street:
Your answer
suite no.:
Your answer
city:
Your answer
state:
Your answer
zip code:
Your answer
CLIENT VEHICLE:
(vehicle you were in at the time of the accident. If none - put N/A)
make:
Your answer
model:
Your answer
year:
Your answer
color:
Your answer
state/license plate no.:
Your answer
regular owner:
(full name)
Your answer
location of your car:
(i.e. home, repair shop, junkyard)
Your answer
address:
Your answer
phone:
Your answer
describe damages:
minor
moderate
major
select one
ACCIDENT INFO:
date: *
MM
/
DD
/
YYYY
time:
Time
:
location:
(i.e. freeway, street address, intersection, alleyway)
Your answer
city and state: *
Your answer
weather:
(i.e. clear, sunny, foggy, rainy, snowy, dark)
Your answer
road condition:
(i.e. light or heavy traffic, construction work, poor street lighting)
Your answer
seat belt in use:
yes
no
N/A
select one
airbags deployed:
yes
no
N/A
select one
hit anything inside the car:
(i.e. headrest, steering wheel, side door)
yes
no
N/A
select one
if yes, describe:
Your answer
car seat:
yes
no
N/A
select one
№ of passengers:
Your answer
driving for a ride-sharing app:
yes
no
N/A
select one
which one:
Your answer
driving within the scope of employment:
yes
no
N/A
select one
POLICE REPORT:
(only if applicable)
law enforcement agency:
Your answer
phone:
Your answer
report no.:
Your answer
officer name:
Your answer
badge no.:
Your answer
BRIEF ACCIDENT DESCRIPTION:
(i.e. traveled from/to, route taken, direction of travel, lane of traffic, lane change, traffic signals, car speed at the time of collision, how the accident happened, point of impact, was your car moving or stopped, any exchange of information with other people, admission of fault)
Your answer
MEDICAL CARE PROVIDERS:
ambulance:
yes
no
select one
emergency room:
yes
no
select one
medical facilities visited for this injury:
(i.e. hospital, urgent care, primary physician, other medical specialists)
1. name/facility:
Your answer
1. address:
Your answer
1. phone:
Your answer
2. name/facility:
Your answer
2. address:
Your answer
2. phone:
Your answer
3. name/facility:
Your answer
3. address:
Your answer
3. phone:
Your answer
Prior accidents/injuries:
1. describe injury:
Your answer
1. year:
Your answer
1. claim filed:
yes
no
select one
1. claim type:
workers compensation
personal injury
select one
2. describe injury:
Your answer
2. year:
Your answer
2. claim filed:
yes
no
select one
2. claim type:
workers compensation
personal injury
select one
CLIENT MEDICAL/HEALTH INSURANCE:
name of insurance:
Your answer
state health insurance: *
MediCal
MediCare
N/A
select one
type:
HMO
PPO
other
unknown
select one
group no.:
Your answer
medical record no.:
Your answer
adjuster/claim admin:
Your answer
coverage used for treatment related to this accident:
yes
no
select one
health insurance phone no.:
Your answer
CLIENT EMPLOYMENT INFO:
employer name:
Your answer
contact name/supervisor:
Your answer
phone:
Your answer
street:
Your answer
suite:
Your answer
city:
Your answer
state:
Your answer
zip:
Your answer
your position:
Your answer
years at job:
Your answer
time missed:
Your answer
hourly rate:
Your answer
hours/week:
Your answer
PARTY AT FAULT (DEFENDANT NAME):
first (or business name): *
Your answer
middle:
Your answer
last: *
(if business - put N/A)
Your answer
DEFENDANT CONTACT INFO:
street: *
Your answer
apt:
Your answer
city: *
Your answer
state: *
Your answer
zip:
Your answer
phone:
Your answer
e-mail:
Your answer
driver license no.:
Your answer
driving for employer:
yes
no
select one
DEFENDANT AUTO INSURANCE:
carrier:
Your answer
policy no.:
Your answer
claim no.:
Your answer
limits:
Your answer
DEFENDANT AUTO INSURANCE CLAIM ADJUSTER:
first:
Your answer
last:
Your answer
defendant adjuster contact:
phone:
Your answer
ext:
Your answer
e-mail:
Your answer
DEFENDANT VEHICLE:
make:
Your answer
model:
Your answer
year:
Your answer
color:
Your answer
state/license plate no.:
Your answer
no. of people in vehicle:
Your answer
describe damages:
Your answer
WITNESS(es):
witness 1:
Your answer
address:
Your answer
phone:
Your answer
witness 2:
Your answer
address:
Your answer
phone:
Your answer
CLIENT HOBBIES:
(i.e. hiking, exercising, mountain biking, reading, playing sports)
hobbies/activities:
Your answer
CASE EXPECTATIONS:
(what do you expect out of this case - cover medical bills, receive monetary compensation in the amount of $, provide for future medical necessities, punish liable party, get what’s reasonable under the case circumstances)
expectations:
Your answer
ADDITIONAL INFORMATION
(if you didn’t answer any of the above questions fully and would like to add more details, please specify the question and describe your answer in depth, or write additional information about this case that you deem important)
additional info:
Your answer
INJURY STATEMENT:
neck:
back:
upper back
mid back
lower back
select
shoulder(s):
left
right
select
knee(s):
left
right
select
leg(s):
left
right
select
limited range of motion:
neck
back
arms
legs
select
fracture(s):
Your answer
sprain/strain:
Your answer
other:
Your answer
Diagnostic procedures performed for this injury:
Location:
(specify body parts where diagnostic studies were performed)
Your answer
Pain area and rating:
Specify 3 most concerning injured areas:
1.
Your answer
Rate your discomfort on a scale of 1-10 (1= mild pain, 10 = the worse pain you’ve ever felt):
2.
Your answer
Rate your discomfort on a scale of 1-10 (1= mild pain, 10 = the worse pain you’ve ever felt):
3.
Your answer
Rate your discomfort on a scale of 1-10 (1= mild pain, 10 = the worse pain you’ve ever felt):
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