Page 1 of 1
PERSONAL INJURY INTAKE FORM
Dates Lost From Work Because of This Injury
*
FROM
To
Total Amount of Employment Compensation Lost:
*
ACCIDENT
Date of Accident:
*
Time of Day
Day of Week
*
Location
*
Weather Conditions
Person who Caused the Accident (If known)
Name (First and Last)
Address
Phone Number
Name of Employer
Defendant Insurance (If Known)
Insurer (Indicate Name, Address & Telephone)
Policy #:
Have you Filed Any Reports With or Made Any Statements to Defendant’s Insurer?
*
Have you Filed Any Reports With or Made Any Statements to Defendant’s Insurer?
A
Yes
B
No
Were there any witnesses of the event
*
Were there any witnesses of the event
A
Yes
B
No
General Description of What Happened
*
Did you file a police report?
*
Did you file a police report?
A
Yes
B
No
Other Reports? (Indicate Date and To Whom)
*
Your Insurance
Policy #
*
Company Name
*
Address
*
Phone Number
*
Agent Name
*
Insurance Claim/Report Made?
*
Insurance Claim/Report Made?
A
Yes
B
No
Prior Accidents Causing Injury to You (Include Dates)
*
Have you ever been a part of any legal proceedings prior (List all prior criminal and civil cases. Please briefly describe each event and provide the court in which the suit was filed, the case number and the final outcome):
*
Submit
