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:___

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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?______

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DO YOU HAVE ANY OTHER INFORMATION YOU WOULD LIKE TO GIVE?______

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