Auto Accident Intake Form

Date form completed

Who can we thank for referring you to us

First Name

Last Name

Email

Phone

Date of the Accident

Location of accident

Driver, passenger, or pedestrian

Driver

Passenger

Pedestrian

Commercial vehicle, big rig, or 18-wheeler involved

Yes

No

Were you at work at the time of the accident

Yes

No

If yes, where do you work

Was the vehicle you were in insured

Yes

No

Unknown

Was the other driver insured

Yes

No

Unknown

Did the police come

Yes

No

Unknown

If the police came, which agency? PD, Sheriff, State Police? Do you have a report number?

Was anyone given a ticket or citation

Yes

No

Unknown

Were you given a ticket for anything

What injuries did you sustain

Medical treatment the day of the accident

Yes

No

If yes, where and when?

Were you taken by ambulance or private vehicle

Ambulance

Private vehicle

Anyone else in vehicle with you

Yes

No

If yes, their name and phone number

Address

Date of birth

Any other details the attorney should know

Request photographs, ID, driver´s license (of the other driver too), car insurance info., health insurance info., police report, accident report, witnesses. Send Fee Agreement and Medical Authorization through MyCase. Set Strategy Session with Lead Attorney.