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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?
A
Rear-ended
B
T-bone
C
Head-on
D
Sideswipe
E
Rollover
F
Uber or Ride Share
G
Truck Hit Me
H
Motorcycle Related
I
Other/Complex/Multi-Car
Were you the:
A
Driver
B
Passenger
C
Pedestrian
D
Bicyclist
E
Motorcyclist
Briefly describe how the accident happened
POLICE & FAULT
Was a police report filed?
A
Yes
B
No
C
Not Sure
Who was at fault?
A
The other driver
B
I was partially at fault
C
I was not at fault
D
Not sure
Did the other driver receive a citation?
A
Yes
B
No
C
Not Sure
Injuries & Treatment
Were you injured?
A
Yes
B
No
What injuries did you suffer?
Neck pain/whiplash
Back injury/pain
Broken bones
Head Injury/concussion
Internal injuries
Cuts/Lacerations/Puncture
Loss of Consortium
Other
Did you go to the ER or urgent care?
A
Yes
B
No
C
Planning to Go
Are you currently receiving treatment?
A
Yes
B
No
C
Planning to Go
How has this affected your day-to-day life?
Financial and Legal Status
Have you missed work or income due to the accident?
A
Yes
B
No
Have you spoken with an insurance company yet?
A
Yes
B
No
Do you currently have an attorney?
A
Yes
B
No
What approximate time do you want to talk to an attorney? We will send you a text.
Submit