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Auto Accident Evaluation - C.M. Brainard & Associates

Full Name

Phone Number

Email Address

ACCIDENT DETAILS

Date of the Accident?

What Time Did the Accident Occur?

City and State Where Accident Happened?

What type of accident was it?

What type of accident was it?
A
B
C
D
E
F
G
H
I

Were you the:

Were you the:
A
B
C
D
E

Briefly describe how the accident happened

POLICE & FAULT

Was a police report filed?

Was a police report filed?
A
B
C

Who was at fault?

Who was at fault?
A
B
C
D

Did the other driver receive a citation?

Did the other driver receive a citation?
A
B
C

Injuries & Treatment

Were you injured?

Were you injured?
A
B

What injuries did you suffer?

What injuries did you suffer?

Did you go to the ER or urgent care?

Did you go to the ER or urgent care?
A
B
C

Are you currently receiving treatment?

Are you currently receiving treatment?
A
B
C

How has this affected your day-to-day life?

Financial and Legal Status

Have you missed work or income due to the accident?

Have you missed work or income due to the accident?
A
B

Have you spoken with an insurance company yet?

Have you spoken with an insurance company yet?
A
B

Do you currently have an attorney?

Do you currently have an attorney?
A
B

What approximate time do you want to talk to an attorney? We will send you a text.