Fill and Sign the Motor Vehicle Accident Questionnaire Form

Motor Vehicle Accident Questionnaire Client name:       Address:       Home phone:       Work phone:       Cell phone:       Birth date:       Social Security Number:       Drivers License Number:       State:       Collision Date of accident:       Time:       Where did the accident occur?       What was the weather at the time of the collision? dry wet icy Were you the: driver passenger pedestrian? If passenger, were you in the front seat right rear seat left rear seat? What type of vehicle were you in?       What type was the other vehicle?       Did your vehicle strike the other vehicle? Yes No Was your car struck by the other vehicle? Yes No What direction was your vehicle traveling?       What direction was the other vehicle traveling?       Where was the impact from?: the front the rear the left side the right side What was the approximate speed at the time of the impact? Your vehicle       mph Other vehicle       mph Was your vehicle in: park neutral in gear moving stopped Were you applying the brakes at the time of impact? Yes No Please describe the collision in your own words:       Did any other part of your body hit the interior of the vehicle? Yes No If yes, please describe which body part and part of interior it hit:       Were you holding on to the steering wheel? Yes No Did the vehicle go into a spin or roll after the collision? Yes No If yes, describe:       Were there skid marks? Yes No Please describe the damage to the outside of the vehicle:       Please describe the damage to the inside of the vehicle:       Were you unconscious dazed conscious immediately after the accident? If you lost consciousness, for how long? Were you wearing a seat belt? Yes No If yes: Did the belt have a shoulder harness? Yes No Did the belt cause any pain? Yes No Were you braced for the impact? Yes No Were you aware that an impact was coming? Yes No Was your vehicle thrust: forward backward sideways? Were you thrust: forward whipped backward? Were the air bags deployed? Yes No Did your seat have a head restraint (headrest?) Yes No If yes, was it positioned high midway low Were you driving? Yes No If no, who was driving your vehicle?       Vehicle owner:       Describe how the accident happened:       Response to Accident Did the police come to the scene of the accident? Yes No Were any citations issued or arrests made? Yes No Do you believe alcohol/drugs/medication was a factor in causing the accident? Yes No If yes, why?       Do you have a copy of the police report? Yes No 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 anyone take pictures of the accident scene? Yes No Did anyone take pictures of your injuries? Yes No 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?       Are you diabetic? Yes No Do you have high blood pressure? Yes No Do you have low blood pressure? Yes No Do you have arthritis or degenerative joint disease? Yes No Are you currently under medical care for injuries due to the accident? Yes No Insurance Were you insured on the day of the accident? Yes No Do you carry uninsured motorist coverage? Yes No Do you have medical coverage for your automobile? Yes No Was the driver of the other vehicle(s) insured? Yes No Was the owner of the other vehicle(s) insured? Yes No Was the driver of the other car also its owner? Yes No Carrier of Client’s Policy:       Address:       Medical coverage? Yes No If yes, limits:       Liability limits:       Collision coverage? Yes No If yes, limits:       Uninsured motorists coverage? Yes No If yes, limits:       Claim Number:       Insured:       Adjuster:       Telephone Number:       Ext.       Carrier of other driver’s policy:       Address:       Medical coverage? Yes No If yes, limits:       Liability limits:       Collision coverage? Yes No If yes, limits:       Uninsured motorists coverage? Yes No If yes, limits:       Claim Number:       Insured:       Adjuster:       Telephone Number:       Ext.       Carrier of other owner’s policy (if different from other driver):       Address:       Medical coverage? Yes No If yes, limits:       Liability limits:       Collision coverage? Yes No If yes, limits:       Uninsured motorists coverage? Yes No If yes, limits:       Claim Number:       Insured:       Adjuster:       Telephone Number:       Ext.       Other Damages and 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 Are your work activities limited due to this accident? Yes No Have you received any increases or decreases in your pay since the accident? Yes No If yes, describe:       Are other activities limited due to this accident? Yes No If yes, describe:       Have you received Social Security benefits or Medicare benefits as a result of this accident? Yes No Since this injury are your symptoms improving worsening same? Where is the vehicle now?       Do you have a criminal record? Yes No If yes, please describe: