CAR ACCIDENT INTAKE FORM(If you do not have some of the information we ask for, we will track it down for you.)PERSONAL INFORMATIONName(s)/ODL#Phone NumberD.O.B MM slash DD slash YYYY Marital StatusSSNDo 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 InfoID/Policy NumberName(s) of Passenger(s)Names and ages of childrenName/adress/phone number of next to kinHave you had another lawyer work on this case? Yes No ACCIDENT FACTSDate MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Location (city/state/neighborhood) of accidentWeather and Road ConditionsBriefly describe how the collision occurredName/ODL # of other driverBelted/Unbelted? Belted Unbelted Your speedOther driver's speedPolice 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 witnessesDESCRIBE THE ACCIDENTWhich 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 DAMAGEMakeModelYearLicense Plate #OwnerLocation of damage to vehicleApproximate amount of damagesName of Auto Body/Repair ShopDo you have any photographs of vehicle damage? Yes No Other Driver's CarMakeModelYearDriverOwnerLocation/approx amount of property damageINSURANCE INFORMATION:Your Insurance Company:Other Driver's Insurance Company:Your Company NameTheir Company NameYour Claim No.Their Claim No.Your Adjuster NameTheir Adjuster NameYour 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 hospitalHow did you get there?If by ambulance, what company?MEDICAL TREATMENT PROVIDERS:(Name/Address/Phone)Doctor #1Is treatment concluded? Yes No Doctor #2Is treatment concluded? Yes No Doctor #3Is treatment concluded? Yes No Doctor #4Is treatment concluded? Yes No Doctor #5Is treatment concluded? Yes No EMPLOYMENT AND INCOME INFORMATIONEmployerEmployer AddressEmployer Phone #Job TitleJob Description/Type of WorkPay RateHours worked/weekLast year's income (approximate)Physical demands of your work; what job tasks have given you problems since the accidentHave you missed time from work because of your injuries? Yes No If so, how many days/hours have you missed?PRIOR AUTO ACCIDENTS AND INJURIESAny 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/conditionLIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS Δ You must complete the form on the next page too, in order for Peterson Law Offices to legally represent you.
