Personal Injury Car Accident Intake Questionnaire

Client Information
Full Legal Name *
Gender (Male / Female): *
Address *
Marital Status *
Date of Birth *
Driver’s License # *
Cell Phone *
Email *
Employer *
Employer Address *
Medical Insurance: *
INJURIES
Injuries you sustained from this accident *
Were you transported to the hospital by ambulance? *
If yes, which hospital? *
Did you visit your family doctor or urgent care? *
If yes, which facility? *
When *
Have you received follow-up medical treatment? *
If yes, list names of doctors, chiropractors, physical therapists *
Have you missed work due to your injuries? *
If yes, how many days/weeks? *
Did you file for disability or time off? *
Have you been involved in any car accident before? *
Date of Prior Accident *
Passenger(s) in Your Vehicle
Were there passengers in your vehicle? *
Number of Passengers: *
If yes, please provide the following details: *
INJURIES
Was the passenger transported to the hospital by ambulance? *
If yes, which hospital? *
Did you visit your family doctor or urgent care? *
If yes, which facility? *
When *
Have you received follow-up medical treatment? *
If yes, list names of doctors, chiropractors, physical therapists *
Have you missed work due to your injuries? *
If yes, how many days/weeks? *
Did you file for disability or time off? *
Have you been involved in any car accident before? *
Date of Prior Accident *
Accident Details
Number of Vehicle(s) involved in the accident *
Date of Accident *
Approximate time *
Location of the Accident (Street, City, State) *
Were you the *
Were you wearing a seatbelt? *
Were there any car seats / booster seats in your vehicle *
Were the police called to the scene? *
If yes, which department? *
Report number *
Was a traffic citation issued? *
If yes, to whom? *
How did the accident happen? (Brief narrative) *
What was the purpose of this trip? *
Any statement made by the other party? *
Name of Witness *
Witness Address *
Do you have photos or videos of the accident, vehicle damage, or injuries? *
Your Vehicle & Insurance Information
Year, Make, and Model of your vehicle *
License Plate # *
Are you the Register Owner of the vehicle? *
If no, who is the Registered Owner? *
Date of Accident *
Registered Owner Address *
Registered Owner’s Auto Insurance Company *
Policy Number *
Driver’s Auto Insurance Company *
Policy Number *
Damage of the vehicle *
Was your vehicle towed? *
Where is your vehicle now? *
Did you report the accident to your insurance company? *
If yes, claim number *
Adjuster name and contact *
Other Party’s Information
Full Name of the Other Driver *
Phone Number *
Address (if available)
Driver’s License # *
Vehicle Information (Year, Make, Model) *
License Plate # *
Damage of the vehicle *
Auto Insurance Company *
Policy Number *
Claim Number (if known) *
Insurance Adjuster Name and Contact Info (if known) *
Was the other party cited by police? *
If yes, for what violation? *
Did the other party admit fault at the scene? *
If yes, what exactly did they say? *
Was the other party driving for work or a commercial purpose? *
If yes, name of company/employer *
Do you believe the other driver was distracted (e.g. phone use), speeding, or under the influence? *