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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?
*
Briefly describe how the accident happened
POLICE & FAULT
Was a police report filed?
A
Yes
B
No
C
Not Sure
Who was at fault
*
Did anyone receive a citation, charge, or ticket?
*
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
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
Submit