CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL 1. Full Name: 2. Other Names Known By: 3. Address: 4. Home Phone: Work Phone: 5. Date of Birth: Age: 6. Social Security Number: 7. Marital Status: 8. Spouse (including maiden name): 9. Spouse s birthdate: 10. Date of Marriage: 11. Children (including names, dates of birth, and ages): 12. List the addresses where you have resided during the past ten (10) years. Address From To - 1 -
LEGAL 1. Please list the dates and circumstances of any previous auto accidents: 2. Please list any lawsuits in which you have been involved. a. Were you the Plaintiff or Defendant? b. In what State and County did it take place? c. What did the lawsuit involve? d. Did you give a deposition or testify in court? If so, name when and where. 2. Please list any traffic violations. 2. Have you ever been convicted of a crime? If so, please explain. 1. Name of Company: INSURANCE Auto - 2 -
2. Address: 3. Policy #: 4. Claim #: 5. Name of Agent: 6. Address of Agent: 7. Agent s Telephone: 8. Have you received any no-fault payments? Health 1. Name of Company: 2. Address: 3. Policy #: 4. Claim #: 5. Name of Agent: 6. Address of Agent: 7. Agent s Telephone: EDUCATION 1. High School: Name: Address: - 3 -
Dates Attended: Graduated (if so, name the year):yes No 2. College/Community College/Technical College: Name: Address: Dates Attended: Course of Study: Degree(if so, name year): Yes No 3. Other (You may also use this area if you attended more than one college, technical college, etc.): Name: Address: Dates Attended: Course of Study: Degree (if so, name year): Yes No MILITARY 1. Were you ever in the Military Service? Yes No If so, state the dates and service branch: EMPLOYMENT 1. Were you employed at the time of the incident?yes No If so, complete the following: a. Employer: b. Address: - 4 -
c. Work Phone #: d. Supervisor: e. Job Title: f. Dates of Employment: From: To: g. Rate of Pay: h. Number of Hours Per Week: i. Average Weekly Overtime: j. Dates you were unable to work because of your injuries: 2. Past Employment (Past 10 years): Employer Address From To Job Title 1. Make, Model, and Year of your vehicle: 2. Owner s Name and Address: VEHICLE 3. Driver s Name and Address: - 5 -
4. Condition of vehicle (brakes, tires, windshield, wipers, headlights, tail lights, turning lights, horn). 5. Driver s License Number: 6. License Plate: 7. Property Damage to Vehicle as a result of the accident: ACCIDENT 1. Date and Time of Accident: 2. Location of Accident: 4. Brief Description of What Happened: 5. Witnesses: 6. Names and addresses of all occupants of each vehicle and the positions in the vehicle, indicating as to each, whether he/she was an owner, driver, passenger, etc. - 6 -
7. As to the vehicle, the purpose of its trip, who was paying the expenses of the trip, why was each person in the car. 8. Had you or any other person in the vehicle been drinking or using chemicals which reduced the quality of judgment? If so, name the chemical, when he/she used it, how much he/she used, and where he/she used it. 9. Was there a police investigation? If so, by what police department? Names of officers? 10. Were citations issued? If so, to whom and what citation was he/she issued? 11. Weather conditions: Road surface (gravel, blacktop, concrete): Road conditions (wet, snowy, dry, dusty, etc): Traffic conditions (light, heavy): 12. Speed of your vehicle: Speed of other vehicle/s: 13. Describe any conversations after the accident with the driver of the other vehicle/s. - 7 -
MEDICAL 1. State all injuries which you received as a result of the accident: 2. Describe your present physical condition scars, deformities, headaches, pain, etc. due to the injuries received in the accident: 3. List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of injuries sustained in the accident: Hospital Address From To 4. List all doctors, chiropractors, dentists, psychiatrists, etc., consulted for your injuries as a result of the accident: Name Address Type of Treatment 5. List all of the activities which you have not been able to perform, or can only perform with difficulty, since the accident (work, household duties, hobbies): - 8 -
6. Please list the name and address of your family physician. 7. List all previous and subsequent accidents, injuries, illnesses, hospitalizations, or other mental or physical problems from birth to the present. Date Illness/Injury Facility Doctor Outcome - 9 -
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