Automobile Accident Intake Form
Please complete this West Law Firm form and click submit.
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PERSONAL INFORMATION
Client's Name *
Address *
Phone Number *
Email *
DOB *
MM
/
DD
/
YYYY
Marital Status *
Spouse Name
Driver's License Number: *
Driver's License State *
HEALTH INSURANCE INFORMATION
Health Insurance *
Insured Name *
Group Number *
Member ID *
Are You a Medicare Beneficiary? *
Are You a Medicaid Beneficiary? *
ACCIDENT INFORMATION
Date of Accident *
MM
/
DD
/
YYYY
Location of Accident (street, city, state) *
What Was Your Role? *
Were You on the Job? *
If Yes, Is Workers' Compensation Involved?
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Describe the Accident *
List All Injuries *
Was There EMS Transport? *
If Yes, What Hospital?
Was There X-ray, CT scan or an MRI? *
Required
List All Other Medical Treatment *
Primary Care Doctor *
Prior Medical Injuries *
Prior Accidents or Claims
List Other Vehicles at Your Home
Police Department at Scene *
Accident Report Number or FR-10 Number
Did You Have Passengers? *
If Yes, Please List
Were There Witnesses? *
If Yes, Please List (names & contact info if available)
Have You Missed Work Due to This Accident? *
If Yes, How Much Time Have You Missed to Date?
If Yes, Employer Name
Your Vehicle Information (year, make, model) *
Owner of Vehicle *
Auto Insurance Company *
Policy Number *
Claim Number *
Adjuster Name & Phone Number
AT-FAULT DRIVER INFORMATION
At-fault Vehicle Information (year, make, model)
Owner of At-fault Vehicle
Name of At-fault Driver
Driver's License
Driver's License State
Auto Insurance
Policy Number
Claim Number
Adjuster Name & Phone Number
Has an Adjuster Contacted You?
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If Yes, Please List:
Submit
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