PERSONAL INJURY INTAKE (Please use additional paper if there is insufficient space for any section)

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1 PERSONAL INJURY INTAKE (Please use additional paper if there is insufficient space for any section) I. YOUR GENERAL INFORMATION Last Name: First Name: MI: Date of Birth: SSN: Street City/State/Zip: Home Work Cell Spouse: Date of Birth: SSN: Child: Child: Child: DOB: DOB: DOB: II. YOUR EMPLOYMENT INFORMATION Employer: Occupation: Weekly/Biweekly Salary: $ No. of Hours Worked Per Day: Supervisor: Date Employment Commenced: No. of Days Worked Per Week: Phone No.: Last Day Worked Before Accident: Date Returned: Light/Restricted Duty? 1

2 How Long Were You Confined to Bed? How Long Were You Confined Home? III. YOUR INSURANCE INFORMATION A. Do you or your spouse have health and/or disability insurance through your employment? _ If your answer is yes, then provide the following information: Name and address of health insurance company through employment: Employer health insurance company s policy no.: Has health insurance through employment paid any benefits for this accident? If your previous answer is yes, approximately how much? Name and address of disability insurance company through employment: Employer disability insurance company s policy no.: Has disability insurance through employment paid any benefits for this accident? If your previous answer is yes, approximately how much? B. Do you have private (not through employment) health or disability insurance? If your answer is yes, please provide the following information: Name and address of private health insurance company: Private health insurance company s policy no.: Has your private health insurance paid any benefits for this accident? If your previous answer is yes, approximately how much? Name and address of private disability insurance company: 2

3 Priviate disability insurance company s policy no.: Has your private disability insurance paid any benefits for this accident? _ If your previous answer is yes, approximately how much? IV. YOUR EDUCATION High School Name: Graduation Date: Post High School Name: Degree(s) obtained and Date: V. ACCIDENT INFORMATION Date of Accident: Day: Time: Location of Accident: Was a public governmental authority, agency, or employee possibly at fault? Yes No If yes, state whom and why you believe they may be at fault: _ What is the address or the intersection where the accident occurred? 3

4 You Were Traveling on What Street/Road? Offending Vehicle Was Traveling on What Street/Road? Weather: Your Position in Vehicle: Describe the accident: Law Enforcement Dept(s). at scene: Officer(s) name(s): Was there emergency care at scene? Yes No If your answer is yes, who/what provided emergency care? Were you transported in an ambulance? Yes No If your answer is yes, what is the name of the ambulance service? Was there fire or other rescue care at scene? Yes No If your answer is yes, which fire or rescue service? 4

5 VI. PLEASE DRAW A DIAGRAM OF THE ACCIDENT BELOW: VII. WITNESSES TO ACCIDENT Witness #1: Name: Phone Number: Witness #2: Name: Phone Number: Witness #3: Name: Phone Number: 5

6 VIII. VEHICLE INFORMATION (if applicable) You were the in Vehicle #1 (Owner/Operator/Passenger) You were a pedestrian. Vehicle No. 1 (Your Vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: Vehicle No. 2 (other party s vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s 6

7 Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: Vehicle No. 3 (other party s vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: 7

8 IX. IF NOT ALREADY LISTED ABOVE, PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT ANY PARTY THAT YOU BELIEVE MAY BE AT FAULT: AT FAULT PARTY #1: Name: Phone Number: Why do you believe they may be at fault? _ Their liability insurance company: The address of their liability insurance company: Liability policy holder: Policy no.: Effective date of policy: Expiration date of policy: AT FAULT PARTY #2: Name: Phone Number: Why do you believe they may be at fault? _ Their liability insurance company: The address of their liability insurance company: Liability policy holder: Policy no.: Effective date of policy: Expiration date of policy: 8

9 X. HOSPITALS/CLINICS WHERE YOU HAVE TREATED FOR INJURIES FROM ACCIDENT Hospital/Clinic #1: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #2: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #3: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #4: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit 9

10 XI. PHYSICIANS THAT YOU HAVE SEEN FOR INJURIES FROM ACCIDENT 1. Doctor s Name: Specialty: 2. Doctor s Name: Specialty: 3. Doctor s Name: Specialty: 4. Doctor s Name: Specialty: XII. ANY PREVIOUS ACCIDENTS? Have you ever been involved in a previous automobile or any other type of accident? Yes No If yes, complete the following: Date: Place: Description: 10

11 Injuries Sustained: List the medical providers who rendered treatment for injuries from prior accident: Did you commence a claim or a lawsuit? Yes No If Yes, Please list the name and address of your prior attorney: XIII. OTHER MEDICAL HISTORY List past physicians of note and current primary or treating physicians below. 1. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 2. Doctor s Name: Specialty: 11

12 Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 3. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 4. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: Do you have any medical conditions or disabilities that pre-date the accident? Yes No If yes, complete the following: What: Date(s): Description of How Sufferred: 12

13 Symptoms/Limitations: List the medical providers who rendered treatment for injuries or symptoms: Do you still suffer from the condition/disability? Yes No If no, when did condition/disability end? Date: Signature 13