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 *
Date of Collision *
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Time of Collision *
Time
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Were you the: *
Your Vehicle *
Make and Model of Your Vehicle
Other Vehicle *
Your Estimated Speed at Time of Collision *
Road Conditions *
Where was your vehicle hit? *
Where did the other vehicle hit your vehicle? *
Did you see the accident coming? *
Were you able to brace for impact? *
Were you wearing a seat belt and shoulder harness? *
Was the seat you were in damaged or broken by the collision? *
Did the airbags deploy? *
Did the airbags hit you? *
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?
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Did you receive any cuts, bruises, bleeding? *
Did you have immediate pain after the accident? *
Please describe all areas (body parts) of pain and when they 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 you examined in an emergency room? *
If yes, what exactly were you told? Do you have the records of the visit? *
Please list any and all symptoms (pain areas) since the collision. *
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?   *
Name, Address, Phone of Insurance Company and the Adjustor's name *
Medical Care and Expenses
Keep detailed records of any and all medical treatment you receive as a result of the accident. Write down any and all visits to hospitals, clinics or doctors’ offices. This includes any type of medical treatment, so physical therapy, mental health appointments and dentist appointments should be documented as well. Keep receipts for all expenditures, including co-pays on office visits. Keep a log of prescriptions, including your out-of-pocket cost for the prescriptions. You will want to keep track of any over-the-counter medication as well. For each and every entry in your log, mark the date and, if possible, the time. Save receipts to prove your expenses.
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