Inquiry form - Motor Accident Page 1

Transcription

1 Inquiry form - Motor Accident Page 1 1. Personal Details i. Full name Date of Birth i Residential address Documents to bring If relevant in your situation : diagram or photo of accident site, police report or Event number, claim form, medical certificates, medical reports, imaging reports, letters from insurer. Postal address (if different) v. Mobile phone number vi. Home phone number v Fax number vi address ix. Drivers License number x. Drivers Licence type xi. Medicare Number x Tax File Number xi Date you last lodged tax return x Centrelink reference number xv. Dependant spouse details? xvi. Dependant children details? xv Do you need an interpreter? Language?

2 Inquiry form - Motor Accident Page 2 2. Accident details i. Accident Date Accident Time i Weather & road conditions Place of accident (street and town or suburb) v. Did Police attend? vi. Was accident reported at a police station? v Date reported vi Event number? ix. Police officer s details x. Do you have a copy of any statements? xi. Did police take any action? What? Against whom? x xi x xv. xvi. xv xvi What was your part in the accident: driver, passenger pedestrian, cyclist, motorcyclist, pillion passenger, other If driver or passenger, was seatbelt worn? Was seat belt fitted to vehicle? If motorcycle/cycle accident, was helmet worn? Had you taken any drugs, alcohol, meds in the 12 hours prior to accident? Details of xvi for your driver/rider if you were passenger? Was accident blameless accident eg sudden illness ofdriver, vehicle failure

3 Inquiry form - Motor Accident Page 3 xix. What happened? Draw Diagram xx. xxi. How many vehicles in accident For Vehicle at fault: Registration number Make & Model Colour Year Drivers full name Driver s license details Drivers contact details Owner s full name Owner s contact details xx For vehicle you travelled in: Registration number Make & Model Colour Year Drivers full name Driver s license details Drivers contact details Owner s full name Owner s contact details

4 Inquiry form - Motor Accident Page 4 xxi For each other vehicle involved: Registration number Make & Model Colour Year Drivers full name Driver s license details Drivers contact details Owner s full name Owner s contact details 3. Witnesses i. For each: Name Address Work Phone Home Phone Mobile

5 Inquiry form - Motor Accident Page 5 4. Injuries & Disabilities i. What parts of the body were injured? What were the injuries (eg sprain, break, burn, psychological, etc) i Which injuries are continuing? 5. Treatment Details i Ambulance? Hospital? First doctor seen about injury was? v. GP treating you is? vi. Specialist/s? v Physiotherapist/s vi Psychologist ix. Who is still treating your injury now? x. Dates of any operations xi. Is any future surgery planned?

6 Inquiry form - Motor Accident Page 6 6. Past Health i. Have you had past injuries to or problem to the same body part? Details Have you had past treatment for a psychological condition? Details i Any chronic conditions? Any unrelated past injuries? v. What GPs have you seen 2 years before the accident? vi. What specialists have you seen 2 years before the accident? 7. Incapacity details i. Effect on activities of daily living Yard/garden/sport/recreation Home care: cooking, vacuuming, making beds, shopping, stair climbing, walking Self care: dressing, washing, toileting, haircare/shaving Pain and suffering details: How has it affected your activities & life?

7 Inquiry form - Motor Accident Page 7 8. Insurance Details i. Have you completed an Accident Notification Form? Have you completed a claim form? i Insurer s Name Claim number v. Address vi. v vi ix. Phone number Claims Officer name Has there been a factual investigation? Do you have a copy of any witness statements? Any doctors seen for insurer? Who? 9. Employment Details i. Employer s contact details Your job description i Your net weekly wage before the accident x Dates off work due to injury 10. Other i. Have you consulted another solicitor about this injury? Details Have you had any past accidents, injuries or injury claims? i Do you have any unavailable dates for appointments?