Preliminary Personal Injury Form

Name:

Address:

City:

State:

Phone:

Home:

Cell:

Email:

Date of Birth:

Date of accident or injury:

Current Employer:

How long?

Any lost days from work?

Are you currently being treated by a doctor/chiropractor?

List medical providers to date for this injury:

Spouses Full Name:

Number of dependents:

Ages:

If you were involved in an automobile accident did you have insurance?

If so, please list the carrier, policy number, effective dates of insurance and any contact person.

Did other driver have insurance?

If so, please state the following (if known): Other drivers name and address, carrier, policy number and contact person:

Have you made a written or oral statement to anyone? A police officer, property owner, insurance agent/adjuster? If so, state to whom the statement was made and when:

Do you know of any witnesses to your accident? If so do you know their names and/or contact information?