PERSONAL INJURY INFORMATION
QUESTIONS TO BE ASKED TO EACH DRIVER:
ACCIDENT INFORMATION:
ACCIDENT DATE:______DAY OF THE WEEK:______
ACCIDENT TIME:______AM PM
LOCATION (BE SPECIFIC):______
______
HOW MANY VEHICLES INVOLVED? ______
VEHICLE INFORMATION: (TO BE USED FOR EACH DRIVER)
DRIVER NAME:______
ARE YOU KNOWN BY ANY OTHER NAMES:______
ADDRESS: ______
______
TELEPHONE: HOME______WORK______
SOCIAL SECURITY #:______BIRTH DATE:______
DRIVER LICENSE #:______STATE:______
RESTRICTIONS:______
OWNER NAME:______
ADDRESS:______
______
TELEPHONE: HOME______WORK______
MAKE, MODEL, YEAR OF CAR:______
COLOR OF VEHICLE:______# OF DOORS:______
LISENCE PLATE #:______STATE:______
IDENTIFYING CHARACTERISTICS:______
DAMAGE FROM THIS ACCIDENT: (DESCRIBE IN DETAIL) ______
______
______
PREVIOUS DAMAGE ON VEHICLE:______
______
WHERE IS THE CAR NOW?______
DIDYOU HAVE ANY PASSENGERS?______HOW MANY?______
NAME:______
ADDRESS:______
TELEPHONE: HOME______WORK______
SOCIAL SECURITY #:______BIRTH DATE/AGE:______
WHERE WE YOU IN THE CAR AT THE TIME OF IMPACT?______
WERE PASSANGERS INJURED?______INJURY TYPE:______
SAFETY RESTRAINT USED?______
(If not immediately family) WHY WAS THIS PERSON WITH YOU?______
______
WHERE WERE YOU GOING TO WHEN THE ACCIDENT HAPPENED?______
______
WHERE WEREYOUCOMING FROM?______
______
DOYOU KNOW THE DRIVER OR PASSANGERS IN THE OTHER VEHICLE?______
IF SO, HOW?______
______
ACCIDENT SCENE:
WEATHER CONDITIONS:______
ROAD CONDITIONS:______
TRAFFIC CONDITIONS:______
HOW MANY LANES IN THE ROAD?______
WAS PASSING ALLOWED?______
ANY TRAFFIC SIGNS?______
ANY TRAFFIC SIGNALS?______
ANY CONSTRUCTION IN AREA?______
ANYTHING WHICH MAY HAVE OBSTRUCTED ANY DRIVER’S VIEW? DESCRIBE:___
______
DID ANY VEHICLE HAVE HEADLIGHTS ON?______
DID ANY VEHICLE HAVE DEFECTIVE EQUIPMENT?______
______
HIW DID ACCIDENT HAPPEN?______
______
______
______
______
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GET AS MUCH DETAIL AS POSSIBLE!
POLICE CALL TO THE SCENE?______WHICH DEPT.?______
OFFICER(S) NAMES:______
DID ANYONE MAKE A STATEMENT AT THE SCENE?______WHAT WAS SAID?____
______
______
______WHO WAS IT SAID TO? ______
HAD ANYONE BEEN DRINKING?______WHO?______
WERE ANY OF THE VEHICLES SEARCHED FOR DRUGS/ALCOHOL? WAS ANYTHING SUSPICIOUS FOUND?______
DID THE POLICE TEST ANYONE FOR ALCOHOL/DRUGS? WHO?______
WAS ANYONE CHARGED WITH A VIOLATION?______WHO?______
WHAT WAS THE CHARGE?______
WAS A POLICE REPORT FILED?______
DID ANYONE TAKE PHOTOGRAPHS OF VEHICLES OR SCENE?______
PROPERTY DAMAGE:
WAS YOUR VEHICLE DAMAGED IN THIS ACCIDENT? DESCRIBE:______
______
______
HAVE YOU OBTAINED ANY ESTIMATES OF REPAIRS?______
LIST GARAGE AND AMOUNT OF DAMAGE:______
______
______
ATTACH COPY OF ESTIMATES:
WHERE IS THE VEHICLE NOW?______
HAS THE VEHICLE BEEN FIXED?______
BY WHO? WHEN? WHAT WAS THE COST?______
______
______
MEDICAL INFORMATION:
WERE YOU INJURED IN THE ACCIDENT? DESCRIBE:______
______
______
______
DID YOU GO TO THE HOSPITAL?______WHICH ONE?______
ADMITTED?______OUTPATIENT? ______RELEASE DATE:______
X-RAYS TAKEN AT HOSPITAL?______HOW MANY?______
WERE YOU TAKEN BY AMBULANCE?______WHICH ONE?______
DID YOU GO TO A DOCTOR?______DATE FIRST SEEN:______
DOCTOR NAME:______
ADDRESS:______
X-RAYS TAKEN:______HOW MANY?______WHO TOOK THEM?______
ANY OTHER TESTS PERFORMED?______WHO DID THEM?______
WHERE WERE THEY DONE?______
LIST ALL MEDICAL PROVIDERS SEEN AS A RESULT OF THIS INJURY:
NAME:______
ADDRESS:______
NAME:______
ADDRESS:______
NAME:______
ADDRESS:______
WHEN DID YOU LAST SEE YOUR DOCTOR?______
WHEN WILL YOU SEE HIM/HER AGAIN?______
DID YOU HAVE ANY PHYSICAL/MASSAGE THERAPY?______
WHERE DID YOU HAVE THIS THERAPY? (Location)______
______
WHO ACTUALLY PERFORMED THIS THERAPY? (Name or Describe Person)
______
WHAT TYPE OF THERAPY DID YOU HAVE?______
______
DATE OF LAST TREATMENT?______NEXT TREATMENT?______
WAS ANYONE ELSE INJURED IN ACCIDENT? DETAILS?______
______
LOST WAGE INFORMATION:
WERE YOU EMPLOYED AT THE TIME OF THIS ACCIDENT?______
NAME OF EMPLOYER:______
ADDRESS:______
TELEPHONE:______OTHER #:______
WHO IS YOUR SUPERVISOR?______
HOW LONG AT THIS JOB?______OCCUPATION:______
IF LESS THAN FIVE YEARS: GIVE PREVIOUS EMPLOYMENT INFORMATION
WHAT IS YOUR NORMAL SCHEDULE? DAYS (WEEK)______HOURS (WEEK)______
HOURS PER DAY______ARE YOU SALARIED OR HOURLY?______
WHAT IS YOUR HOURLY WAGE?______OVERTIME RATE:______
ARE YOU WORKING NOW?______LIMITATIONS?______
IF LOST TIME FROM WORK:
REGULAR HOURS LOST:______
OVERTIME HOURS LOST:______
TOTAL LOSS OF WAGES TO DATE:______
DO YOU EXPECT TO LOSE MORE?______HOW MUCH?______
WITNESS INFORMATION:
WERE THERE ANY WITNESSES TO THIS ACCIDENT?______
NAME:______
ADDRESS:______
______
TELEPHONE: HOME______WORK______
SOCIAL SECURITY #______BIRTH DATE/AGE:______
WHAT DID THEY SEE/HEAR?______
______
______
DO YOU HAVE ANY OTHER INFORMATION YOU WOULD LIKE TO GIVE?______
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