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 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 FACTSDate MM slash DD slash YYYY Time : Hours Minutes AM PM Location (city/state/neighborhood) of accident Weather and Road Conditions Briefly describe how the collision occurredName/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 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 DAMAGEMake 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 CarMake 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 INFORMATIONEmployer 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 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/condition LIST 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.
