Fill and Sign the Injury Questionnaire 497426841 Form

Claim of Negligence Questionnaire Client name:       Address:       Home phone:       Work phone:       Cell phone:       Birth date:       Social Security Number:       Drivers License Number:       State:       THE ACCIDENT Date of accident:       Time:       Location:       Owner of property at accident location: Name:       Address:       Home phone:       Work phone:       Cell phone:       What were the weather conditions at the time of the accident?       Describe how the accident happened:       What were you doing immediately prior to the accident?       What do you think could have been done to prevent the accident?       Do you think anything could have been done to make the accident less serious? Yes No If yes ,please describe:       Are you aware of any previous complaints about the situation/location? Yes No If yes ,please describe:       RESPONSE TO ACCIDENT Did you make any oral or written statements at the scene of the accident? Yes No If yes ,please describe statement and to whom:       Did you read and sign the statement? Yes No Do you have a copy of the statement? Yes No Did you make any oral or written statements after the accident, such as to an insurance adjuster? Yes No If yes ,please describe statement and to whom:       Did you read and sign the statement? Yes No Do you have a copy of the statement? Yes No Did the police come to the scene of the accident? Yes No Do you have a copy of the police report? Yes No Were any citations issued or arrests made? Yes No Did anyone take pictures of the accident scene? Yes No Did anyone take pictures of your injuries? Yes No Do you believe alcohol/drugs/medication was a factor in causing the accident? Yes No If yes, why?       Witness information: Name:       Address:       Home phone:       Work phone:       Cell phone:       Name:       Address:       Home phone:       Work phone:       Cell phone:       Name:       Address:       Home phone:       Work phone:       Cell phone:       Name:       Address:       Home phone:       Work phone:       Cell phone:       INJURIES Were you injured in the accident? Yes No Were you taken to the hospital? Yes No If yes, name of hospital:       If yes, name of doctor:       If by ambulance, did the ambulance attendants place you in a neck brace back brace other       Did you get any medication or medical supplies? Yes No If yes, describe:       Did you have x-rays taken at the hospital? Yes No What medical treatment have you received?       How often did you see the doctor?       How long did you see the doctor?       Next visit scheduled:       Diagnosis:       Have you had any similar problems before? Yes No If yes, explain:       Have you ever been rejected for military service because of physical, mental, or other reasons? Yes No If yes, explain:       Do you wear glasses, contact lenses, or any prosthetic devices? Yes No If yes, explain:       Is there any limitation on your driver’s license to operate? Yes No If yes, what is the limitation?       Have you ever been treated for alcohol or drug use? Yes No If yes, explain:       Have you ever been denied health or life insurance because of your health? Yes No If yes, by which company, and why?       OTHER DAMAGES/MISCELLANEOUS List here every claim you have ever made for personal injury or property damage: Date Against Whom Type of Claim Lawsuit Filed Result                                                                                           What type of work do you do?       Have you lost any days of work from this injury? Yes No If yes, give dates:       Have you lost any overtime from work from this injury? Yes No If yes, give dates and times:       Was time off authorized by a doctor? Yes No Have you received any increases or decreases in your pay since the accident? Yes No If yes, describe:       Have you received Social Security benefits, workers’ compensation, or Medicare benefits as a result of this accident? Yes No Are your work activities limited due to this accident? Yes No Are other activities limited due to this accident? Yes No If yes, describe:       Since this injury are your symptoms improving worsening same? Were others involved or injured at the same time? Yes No If yes, describe and provide contact information:       Did you have any property damages as a result of the accident? Yes No If yes, describe:       Please provide the following dates and dollar amounts: Date Lost Wages Lost Overtime Medical Care Medication/Medical Supplies Transportation Other                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       INSURANCE Your insurance policy: Carrier:       Address:       Medical coverage? Yes No If yes, limits:       Liability limits:       Claim Number:       Insured:       Adjuster:       Telephone Number:       Ext.       The other party’s insurance policy: Carrier:       Address:       Medical coverage? Yes No If yes, limits:       Liability limits:       Claim Number:       Insured:       Adjuster:       Telephone Number:       Ext.       Telephone Number:       Ext.       Do you have a criminal record? Yes No If yes, please describe: