First Name: Last Name: Preferred Name: Salutation (Mr, Mrs, etc) Mr. Mrs. Ms. Mx. Dr. Miss Hon. Rev. Rabbi Rep. Sen. Master Sir Lady Address: City: State: Zip Code: Phone Number: Email Address: Date of Birth: Social Security Number: Drivers License: Marital Status Please Select (Unknown/Not stated) Never Married Married Divorced Separated Widowed Domestic Partners Spouse Name At the time of the accident, were you in the course of your Employment? --- Yes No Have you lost time from work as a result of your injuries? --- Yes No Employer Name: If you have lost time from work or in the course of employment, please provide Employment information. Position: Employer Address: Employer Phone #: Nearest Living Relative First Name: Please provide the name, address, phone number, and email address of your nearest living relative. Nearest Living Relative Last Name: Relationship Please specify your relationship - Spouse, Child (daughter/son), Parent (Mother/Father), Aunt, Uncle, Niece, Nephew, etc. Nearest Living Relative Phone #: Nearest Living Relative Address: City: State: Zip Code: Nearest Living Relative E-mail Address: Date of Accident: Type of Accident: ---- Auto Accident Dog Bite Motorcycle Accident Other Pedestrian Slip and Fall Wrongful Death If Other, please list the Accident Type: Location of Accident: (City/State) If the accident occurred in a business, private home or property, please include a full address and the name of the company and/or owner of the property the accident occurred in/on. Incident Information: Please describe the incident. Was an Accident Report Filed? --- No Yes Were you charged for the Accident? --- No Yes Were you wearing a Seatbelt? --- No Yes What was your location in the Vehicle? --- Driver Passenger Did you use the Ambulance? --- No Yes Did the airbags deploy? --- No Yes Was the vehicle totaled? --- No Yes Were there any Witnesses? --- No Yes Name of Witness(s): List all injuries resulting from the Accident: Please specify "Right" or "Left" when applicable. For Example: Headaches, back pain (upper, Mid, Lower), Neck pain, shoulder pain (right/left/both), Arm Pain, Leg pain, etc. Do you have any prior accidents or Injuries? --- No Yes List all prior accidents and injuries: Please list all date(s) of accident(s) and approximate dates even if no injuries resulted. Did you go to the Hospital following the accident? --- No Yes If Yes, when did you go to the Hospital? Were you admitted at the Hospital? --- No Yes Please list all medical facilities you have sought treatment for the injuries resulting from the Accident: Include facility name, doctor name, and address Name of your Auto Insurance Company: (If you do not have Auto Insurance please type "N/A" in the space provided) Your Insurance Policy Number: Your Insurance Claim Number: (If you don't have one just leave blank.) Name of At Fault Insurance Company: At Fault Insurance Policy Number: At Fault Insurance Claim Number: (If you don't have one just leave blank.) Name of Health Insurance: (If you do not have health insurance just type "N/A" in the space provided) Health Insurance Member Number: Health Insurance Group Number: Name of Insured/Policy Holder: How did you hear about us? If a friend referred you, please include his/her name.