Peterson Law Offices: Car Accident Intake Form

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CAR ACCIDENT INTAKE FORM
(If you do not have some of the information we ask for, we will track it down for you.)
PERSONAL INFORMATION
Name(s)/ODL#
Phone Number
D.O.B
Date Format: MM slash DD slash YYYY
Marital Status
SSN
Do you have Medicare?
- Yes
- No
Medicaid?
- Yes
- No
If not, are you eligible?
- Yes
- No
Do you have medical insurance?
- Yes
- No
Name of Medical Insurance Co.
Medical Insurer Contact Info
ID/Policy Number
Name(s) of Passenger(s)
Names and ages of children
Name/adress/phone number of next to kin
Have you had another lawyer work on this case?
- Yes
- No
ACCIDENT FACTS
Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Location (city/state/neighborhood) of accident
Weather and Road Conditions
Briefly describe how the collision occurred
Name/ODL # of other driver
Belted/Unbelted?
- Belted
- Unbelted
Your speed
Other driver's speed
Police on the scene (State, City, or County)?
Was a Police Report filed?
- Yes
- No
Was a DMV Report filed?
- Yes
- No
Was the other driver cited?
- Yes
- No
Were there any witnesses?
- Yes
- No
The names and contact information of all witnesses
DESCRIBE THE ACCIDENT
Which street were you traveling on?
Which direction?
The other car hit you where?
What was the cross street, mile post, or nearest landmark?
Your details of what happened
(ex: exact location, situation, Cops, Hospital/Ambulance)
PROPERTY DAMAGE
Make
Model
Year
License Plate #
Owner
Location of damage to vehicle
Approximate amount of damages
Name of Auto Body/Repair Shop
Do you have any photographs of vehicle damage?
- Yes
- No
Other Driver's Car
Make
Model
Year
Driver
Owner
Location/approx amount of property damage
INSURANCE INFORMATION:
Your Insurance Company:
Other Driver's Insurance Company:
Your Company Name
Their Company Name
Your Claim No.
Their Claim No.
Your Adjuster Name
Their Adjuster Name
Your Adjuster Phone #
Their Adjuster Phone #
Was a statement given to your aduster?
- Yes
- No
Was a statement given to their adjuster?
- Yes
- No
INJURIES:
What parts of your body were injured?
Did you go to the doctor/hospital immediately after the accident?
- Yes
- No
Name/phone # of doctor or hospital
How did you get there?
If by ambulance, what company?
MEDICAL TREATMENT PROVIDERS:
(Name/Address/Phone)
Doctor #1
Is treatment concluded?
- Yes
- No
Doctor #2
Is treatment concluded?
- Yes
- No
Doctor #3
Is treatment concluded?
- Yes
- No
Doctor #4
Is treatment concluded?
- Yes
- No
Doctor #5
Is treatment concluded?
- Yes
- No
EMPLOYMENT AND INCOME INFORMATION
Employer
Employer Address
Employer Phone #
Job Title
Job Description/Type of Work
Pay Rate
Hours worked/week
Last year's income (approximate)
Physical demands of your work; what job tasks have given you problems since the accident
Have you missed time from work because of your injuries?
- Yes
- No
If so, how many days/hours have you missed?
PRIOR AUTO ACCIDENTS AND INJURIES
Any prior auto accidents? (list dates, place, and injuries)
Did you make a claim or receive money from prior accident?
- Yes
- No
Approximately how much did you receive?
Any prior on the job injuries? (date, employer, and injury)
Did you receive an award?
- Yes
- No
If so, how much?
Do you have any prior medical conditions, such as prior injuries, that might be aggravated or affected by the injuries suffered in this accident?
- Yes
- No
If so, please list your medical providers for the injury/condition
LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS

You must complete the form on the next page too, in order for Peterson Law Offices to legally represent you.

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All information contained in this web site is designed for general information purposes only. Some of the photographs in use on this site may be professional images or clip art, taken with models or actors, and are not necessarily clients or employees of Peterson Law Offices. Some images may have been obtained through Creative Commons licensing. Information present herein should not be construed to be formal legal advice nor the formation of an attorney/client relationship. Each case and outcome is different. None of the content on this site is intended to imply a certain result or monetary recovery so consult a lawyer to discuss your claim. InjuryLawOregon is a registered trademark of Peterson Law Offices & Todd A. Peterson and all unauthorized use is strictly prohibited.

PERSONAL INFORMATION

ACCIDENT FACTS

DESCRIBE THE ACCIDENT

PROPERTY DAMAGE

INSURANCE INFORMATION:

INJURIES:

MEDICAL TREATMENT PROVIDERS:

EMPLOYMENT AND INCOME INFORMATION

PRIOR AUTO ACCIDENTS AND INJURIES

LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS