AUTO ACCIDENT OR WORK INJURY PAPERWORK

ACCIDENT/INJURY QUESTIONNAIRE
Name

First NameMiddle NameLast Name
Today's Date

MonthDayYear
Date
- AUTOMOBILE ACCIDENT
  
  Additional Information
- Was anyone else in the vehicle with you?
- Number of people
- You were?
- Name of Driver
  if not self
- Name of Driver of other vehicle
- Did airbags deploy?
- Did Police arrive?
- Using Seatbelt?
- Did you strike the windshield or object in car?
- Describe
- Were you knocked unconscious?
- How long?
- Where was your vehicle impacted?
  
  Other
- Where was the other vehicle impacted?
  
  Other
- Your Auto Insurance
- Policy #
- Claim #
- Phone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Other's Auto Insurance
- Policy #
- Claim #
- Phone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- WORKER’S COMPENSATION INJURY
  
  Additional Information
- Employer
- Occupation
- Claim #
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Contact Person
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- GENERAL ACCIDENT/INJURY INFORMATION
- Date of Accident
  
  MonthDayYear
  Date
- Time
  
  :HourMinutesAM/PM Option
- Please describe the accident in as much detail as possible
- Before the accident/injury:
- Have you ever had any complaints in the involved area before?
- If yes - Were they present at the time of the accident/injury?
- If yes — Summarize these complaints prior to the accident:
- Were you capable of performing all of your work activities without restriction?
- At the time of the accident/injury:
- Did you feel pain immediately after the accident?
  
  Other
- Were you taken anywhere after the accident?
  
  Other
- If yes, How?
- If yes, Where?
- If yes, Did you receive treatment?
- Describe
- Since the accident/injury:
- Are your symptoms:
- Are your work activities restricted as a result of this accident/injury?
- If yes — How?
- Have you missed any work since this accident?
- If Yes, dates?
- Have you retained an Attorney?
- Name
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Patient Number
  Skip if not known yet
- Should be Empty:

ACCIDENT/INJURY QUESTIONNAIRE

AUTOMOBILE ACCIDENT

WORKER’S COMPENSATION INJURY

GENERAL ACCIDENT/INJURY INFORMATION