MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST

Transcription

1 EQUILAW Solicitors Ph: Market House 4 Market Street Muswellbrook NSW 2333 Fax: info@equilaw.com.au equilaw.com.au MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST Bring this completed questionnaire with you when you attend your first appointment. 1. Personal Details Title: Surname: Given Names: Have you ever been known by another name?: Yes No If yes, provide details: Residential address: Postal address: (if differs) Medicare No. Birth date: Age: Country of birth: Home Ph: Mobile no.: Work Ph: Fascimile: 2. Interpreter Do you need an interpreter to help you with your claim? language? Yes No If Yes, what language 3. Driver s Licence Have you ever held a Driver s Licence? Yes No Year first licenced: Driver s Licence No. Please provide a copy of your Driver s License Has your Licence ever been cancelled or suspended? Yes No If Yes, reason for cancellation or suspension page 1 of 28

2 4. Previous advice in relation to accident Have your previously seen a solicitor in respect to this accident? Yes No If Yes, provide details: Solicitor Firm Name & Address Phone Appt. Date 5. Drivers Licence Have you ever held a Drivers Licence? Yes No Year first licenced: Drivers Licence Number Has your licence ever been cancelled or suspended? Yes No Reason for cancellation or suspension: 6. Employment What was your employment situation before the accident? Self employed Full Time Part Time Retired Casual Student/child Home Duties Not Working Other (provide details) Pensioner (provide details) Details: Have you lost income because of the accident? Yes No Are you still losing income? Yes No page 2 of 28

3 6. Employment continued Is the work you do, or are your weekly earnings different, because of the accident? Yes No If Yes, Please provide details below: How many separate periods of time have you been away from work because of the accident? (include short periods when you went for treatment or rehabilitation) Work time lost (weeks/days/hours) Date from Date to Have you returned to work? Yes No If No, when do you expect to return to work? Don t know Employment details Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. page 3 of 28

4 6. Employment continued Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. Do you have a copy of your last payslip prior to the accident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Second job Did you have a second job before the accident? Yes No Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. page 4 of 28

5 6. Employment continued Do you have a copy of your last payslip prior to the accident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Self Employment Have you lost income from self-employment in your business because of the accident? Yes No Not applicable Name of business Nature of business Workplace address Phone Estimated earnings loss (Give details of how much you believe you have lost and how you calculated the amount. You will be asked to give CTP insurers copies of your taxation returns, group certificates and assessment notices where available.) If you are self employed have you hired anyone to replace you? Yes No If yes, give details of replacement including name, address, duties perfomed and cost. If no, explain why not. If you were self employed, did you have a second job before the accident? Yes No Have you received or will you receive any money for being unable to work because of your injuries? (e.g. sick leave or holiday pay, social security benefits, workers compensation or insurance payment.) Yes No If yes, please provide details: page 5 of 28

6 7. Financial Details Accountant Accountant s Name Phone Address Tax Returns Do you have completed tax returns for the period 5 years to date? Yes No - If Yes, please provide a copy. Financial Advisor Do you have a Financial Advisor? Yes No If Yes, please provide the following details. Financial Advisor s Name Phone Address Super Fund Are you in a Super Fund? Yes No If Yes, please provide the following details. Name of Super Fund Phone Address Bank Details Bank Name Account Name BSB No. Account No. page 6 of 28

7 8. Marital Status Married (legal or defacto) Single Separated Divorced Widowed If you are married, do you have a copy of your Marriage Certificate? Yes No - If Yes, please provide a Certified Copy of your Marriage Certificate to this firm. Spouse s Name Spouse s Birth Date Spouse Employed? Yes No Name of Spouse s Employment Spouse s Workplace Address Spouse s Gross Weekly Earnings Spouse s Nett Weekly Earnings 9. Children Do you have Dependent Children? Yes No Name Date of Birth 10. Tertiary Education or Qualifications Do you have a tertiary education? Yes No Institute Year Qualification page 7 of 28

8 11. Details of Accident Time Date Location Street Name Were you carrying out duties for your employer at the time of the accident? Yes No If so, please provide name and address of employer: Have you made a claim for Workers Compensation? Yes No If yes, please provide details of the Workers Compensation Insurer. Have you been given a Workers Compensation Claim Number? Yes No If so, please provide Claim Number Have you received weekly payments of compensation? Yes No If yes, please provide details of your payments below. Are you required to wear prescription glasses while driving? Yes No - If the answer is Yes to the question above, were you wearing your glasses at the time of the accident? Yes No Do you require a hearing aid? Yes No - If the answer is Yes to the question above, were you wearing a hearing aid at the time of the accident? Yes No Were you a driver or a passenger in the motor vehicle? If you were a driver or passenger, was a seat belt fitted to the vehicle? Yes No If you were a driver or a passenger, were you wearing a seat belt? Yes No If you were on a motorbike or a bicycle, were you wearing a helmet? Yes No Had you taken any drugs, including medication or alcohol in the 12 hours before the accident? Yes No page 8 of 28

9 11. Details of Accident continued If you were a passenger in a motor vehicle or a passenger on a bicycle or motorbike, had the driver or rider taken any drugs, including medication or alcohol in the 12 hours before the accident? Yes No - If so, please give details below Please provide a description of the accident (including who you consider caused the accident and how the accident happened. page 9 of 28

10 11. Details of Accident continued Draw a diagram of the accident. Include intersections, streets, roads and their names. Show the point of impact and position of all motor vehicles. page 10 of 28

11 11. Details of Accident continued Lane Markings Yes No Gradient Curve Intersection Yes No Traffic Lights Yes No Sealed Road Yes No Gravel Road Yes No Head Lights Yes No Street Lights Yes No Direction you were travelling Direction other vehicle was travelling Estimated speed on impact of your vehicle Estimated speed on impact of other vehicle Did you use your horn? Yes No Did the other driver use their horn? Yes No Skid Marks Yes No How long were the skid marks? Position where vehicles came to rest Did you take any evasive action to avoid the collision? Yes No - If the answer is Yes to the question above, what evasive action did you take? What was the reason for your journey at the time of the collision? page 11 of 28

12 11. Details of Accident continued What time did you start your journey? am pm Where had you been on the day or evening prior to the collision? What in your opinion was the condition of the road surface at the collision scene? What was your speed 100 metres prior to the collision? What was our speed 50 metres prior to the collision? At the time of the collision, what was your speed? km/h km/h km/h When did you first see the other vehicle involved in the collision? What was the position of this other vehicle on the road? What was your position/distance on the road in relation to the left hand kerb? Were any warning signs made by either driver? Yes No - If the answer to the question above is Yes, please provide detail. How well do you know the section of road where the collision occurred? How often do you travel this section of road? What were the weather conditions at the time of the collision? page 12 of 28

13 11. Details of Accident continued In your opinion, who was responsible for this collision? Please provide a reason for your answer to the question above. 12. Motor Vehicles Involved in the Accident How many motor vehicles were involved in the accident? Do you know the registration number of the motor vehicle you consider caused the accident? Yes No If so, complete Section A below: A. Details of Motor vehicle considered to have caused the accident Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). Name of property damage or comprehensive insurer (if known). page 13 of 28

14 12. Motor Vehicles Involved in the Accident continued Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address Were you travelling in this vehicle? Yes No - If no, provide details of the vehicle you were travelling in - Section B B. Details of vehicle you were travelling in Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). page 14 of 28

15 12. Motor Vehicles Involved in the Accident continued Name of property damage or comprehensive insurer (if known). Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address C. Other vehicle involved in the accident Provide details of any other vehicle(s) involved in the accident Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). page 15 of 28

16 12. Motor Vehicles Involved in the Accident continued Name of property damage or comprehensive insurer (if known). Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address D. Complete this section if you were driving a vehicle at time of accident If you are not the registered owner of the vehicle, did you have permission from the registered owner to be driving this vehicle? Yes No In what mechanical condition was the vehicle you were driving? Were you aware of any mechanical defects with this vehicle? Yes No E. Other Driver Was the other driver in the apparent employ of another person? Yes No If so, whom? Did the other driver appear to be under the influence of alcohol? Yes No page 16 of 28

17 13. Pedestrian If you were a pedestrian did you attempt to cross the road via traffic lights? Yes No Did you attempt to cross the road on a pedestrian crossing? Yes No In which direction were you looking as you crossed the road? Left Right Please describe in detail the point of impact of the car with you? Please describe the impact were you struck front on, or was it a glancing type impact? What part of the vehicle struck you? Where on the roadway did you come to rest? Did you come to rest in front of the vehicle or behind it? What are your recollections following the accident? page 17 of 28

18 14. Witnesses to the Accident and Others Involved Were there any passengers with you in your vehicle at the time of the collision? Yes No If the answer is Yes to the question above, please provide their names. Name Address Phone Were there any passengers in the other vehicle at the time of the collision? Yes No If the answer is Yes to the question above, please provide their names.. Name Address Phone Were there any other person/s who witnessed the collision? Yes No If the answer is Yes to the question above, please provide their names. Name Address Phone page 18 of 28

19 15. Police Was the accident reported to a Police Station? Yes No If so, when and to whom? Date Name Station Event Number Did the Police come to the accident scene? Yes No Did you make a statement to the Police? Yes No - If so, please provide a copy. Did any one else make statements? Yes No - If so, whom? (Please provide copies if you have them) If the answer is Yes to the question above, please provide their names. Name Address Phone Did you sign the Police Officer s Note Book? Yes No Were any charges laid against you? Yes No Were any charges laid against the other drivers? Yes No Provide details of who charges were laid against. Name Registration Plate Number Charge (if known) page 19 of 28

20 15. Police continued Are you aware of the current status of the investigation into the accident? Yes No If yes, please provide details. Did the matter proceed to Court? Yes No Provide details of the Court (if known) Do you recall any conversations that you had with the police officers at the scene? Yes No Please provide details of the conversation below. What comments did they make to you in regards to who s fault the accident was? 16. Medical Ambulance Did you require an ambulance on the day of the accident? Yes No Do you recall any conversations that you had with the ambulance officers treating you at the scene? If so please outline what those conversations were. Yes No page 20 of 28

21 16. Medical continued Hospital Did you go to a hospital after the accident? Yes No If so, which hospital? Were you treated at the hospital? Yes No Date treated Were you admitted to the hospital? Yes No Date admitted Have you been discharged from the hospital? Yes No Date discharged Medical Treatment Before the Accident Name of your normal Medical Practitioner: Please list all Medical Practitioners you have seen in the last 5 years: Name Speciality Name, Address & Phone No. of Surgery Treatment ongoing? (Yes/No) page 21 of 28

22 16. Medical continued Medical Treatment Since the Accident Please list all medical treatment providers you have seen since the accident, including GP s, specialists, hospitals, physiotherapists, chiropractors and any other treatment providers. Name Speciality Name, Address & Ph of Surgery Treatment ongoing? (Yes/No) Have you had any x-rays, CT scans or investigations undertaken since the accident? Yes No If so, please provide details below. Date Type Where - If so, please provide copies of all reports, documents, x-rays, CT Scans or any other investigations in relation to medical treatment since the accident. Have you received any Medical or Workcover Certificates? Yes No - If so, please provide copies of these Certificates. Have any treatment or rehabilitation plan(s) that has been developed for you? Yes No If so, provide details on next page. page 22 of 28

23 16. Medical continued Name Address & Phone number Treatment 17. Out of Pocket Expenses Have you incurred any out of pocket expenses in relation to the accident? (e.g. medical appointments, travel to and from appointments, pharmacy expenses) Yes No - If yes, please provide details below AND provide us with copies of receipts. Date Details of Out of Pocket Expenses Paid or Un (tick) page 23 of 28

24 17. Out of Pocket Expenses continued Have you incurred any out of pocket expenses in relation to the accident? (e.g. medical appointments, travel to and from appointments, pharmacy expenses) Yes - If yes, please provide details below AND provide us with copies of receipts. No Date Details of Out of Pocket Expenses Paid or Un (tick) page 24 of 28

25 18. Injuries Please list your injuries from the accident. (List all injuries and affected areas of the body) How do these injuries affect you now? (The effect of your injuries may change over time) Previous Injuries Have you had any other injuries, disability or illness, before or since the accident to the same part(s) of your body? Yes No If yes, please provide details below Date Injury or Illness Treatment Doctor s Name Address (practice or surgery) Have you ever made a claim for personal injury compensation, workers compensation or other damages? (eg.slip & fall, assault, medical negligence, motor accident) Yes No If yes, please provide details below. Date of Injury Insurance Company Claim or Reference no. Type of Claim page 25 of 28

26 19. Care Have you required personal assistance or care at home since the accident? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you required assistance around the house, including cleaning, gardening, mowing, or any other duties? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Name Address Phone (home, work & mobile) Dates & Hours per day Have you required assistance in getting to and from medical appointments? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you for any of this assistance? Yes No page 26 of 28

27 20. Photographs Do you have any photographs of the vehicles at the collision scene? Yes No Do you have any photographs of your damaged vehicle? Yes No Do you have any photographs of injuries you received in the collision? Yes No Do you have a recent photograph of yourself? Yes No - If the answer in any of the questions above is Yes, please provide copies 21. Additional information Do you wish to add anything further? Yes No If so, please indicate what you wish to add. 22. Declaration Do you declare the information you have supplied is true and correct to the best of your knowledge and belief? Yes No Signature Witness Dated page 27 of 28

28 23. Checklist Before attending your initial appointment, please ensure that you have attached copies of the following documents, if you have them. Page 1 Driver s Licence Copy of your current driver s licence. Page 3 Employment Copy of your Contract of Employment. Page 4 Employment Copy of your Award. Copy of your last payslip prior to the accident. Pages 4 Second Job Copy of your Contract of Employment. Copy of your Award. Copy of your last payslip prior to the accident. Page 6 Tax Returns Copies of your Tax Returns for the period 5 years prior to the accident to date. Page 7 Marriage Certificate Certified Copy of your Marriage Certificate. Page 19 Police Copy of your Statement to the Police. Copies of anyone else s Statement to the Police. Page 22 Medical Treatment Copies of any x-rays, CT Scans or any other investigations. Copies of any Medical or WorkCover Certificates. Page 23 Out of Pocket Expenses Copies of any receipts that you may hold. Copies of any receipts that you may hold in relation to payments made by the insurer. Page 27 Photographs Copies of any photographs that you may have of the vehicles at the collision scene, damage to your vehicle or your injuries.. A recent passport size colour photograph of yourself. page 28 of 28