Motor Vehicle Accident
Car accidents are trying life events. An accident can be physically, financially, and emotionally draining. Texas is a fault state, meaning that the driver at fault in the accident will be responsible for paying the medical expenses of the injured party. This is only the case if you are not more than 50% responsible for causing the accident.

Generally speaking, you are likely entitled to a claim if you were injured as a result of another individual’s negligence. Until the at-fault driver is forced to pay for your losses, you must cover them yourself. It is essential that you attend all medical appointments and therapy sessions as failure to attend these appointments may result in the defense challenging the validity of your injuries, possible lowering the damages awarded.
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Email *
Name *
Date of Birth
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DD
/
YYYY
Date of Collision *
MM
/
DD
/
YYYY
Time of Collision *
Time
:
Make and Model of Your Vehicle
Other Vehicle *
Were you the *
Were you wearing a seat belt and shoulder harness? *
Did the airbags deploy? *
Did the airbags hit you? *
If yes, where?
Face, chest?
Was the seat you were in damaged or broken by the collision? *
How badly was the vehicle you were in damaged?
Clear selection
How badly was the other vehicle damaged?
Clear selection
Your Estimated Speed at Time of Collision *
Other Vehicle's Estimated Speed at Time of Collision *
Road Conditions *
Visibility *
Where was your vehicle hit? *
Where was the other vehicle hit? *
Did you see the other vehicle coming? *
Were you able to brace for impact? *
What was your body position at the time of the collision? *
Examples:
Head straight or head turned
Position of hands on steering wheel
Using phone
Were you rendered unconscious by the collision? *
Were you able to move all your body parts after the collision? *
Were you able to get out of the vehicle unaided?
Clear selection
Did you receive any cuts, bruises, bleeding? *
Please describe exactly what happened to you after the collision? 
For example: Head hit the steering wheel or knees hit the dashboard.
Did you have immediate pain after the accident? *
Please describe all areas (body parts) of pain and when the pain started *
For example: Neck pain began immediately or Neck pain began the next day.
Did you receive any medical attention at the accident? *
Were you transported by ambulance? *
If yes, where? *
Were any tests done like X-rays?
What was the diagnosis and treatment provided?
Were X-rays taken? Was medication prescribed?
Were you examined in an emergency room? *
If yes, what exactly were you told? Do you have the records of the visit? *
If you did not have medical care immediately after the accident, where did you go?
Home, work?
Please list any and all symptoms (pain areas) since the collision and how soon they started. *
For example: pain started one hour later, several hours later, next day.
Rate your overall pain level right now. *
0 = no pain    10 = agony
Please list all things with which you have difficulty since the collision. *
Examples: I can no longer bend over to tie my shoes. I cannot look up or reach up my arm above my head. It hurts to walk up or down the stairs. I cannot exercise.
Have you lost any time from work? *
If yes, give last day worked or how many days missed. *
Did you have any physical complaints before the accident?   *
Have you ever been involved in an accident before?   *
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