Personal Injury Form Auto Injury Information Name * Today's Date Date of Accident * Time of Accident * Location of Accident * Type of Accident * Auto/Traffic Work/On Job At Home OtherOther Describe how the accident happened in your own words. * Name of Hospital Attended by Dr. Were you x-rayed at the hospital? Yes No What was the diagnosis? Were you admitted to the hospital? Yes No How long did you stay? What treatment was rendered? What recommendations were made? List any other doctors you have seen as a result of this accident. Have you lost any time from work because of this accident? * Yes No Give days of disability. Totally disabled from: Totally disabled to: Partially disabled from: Partially disabled to: Have you returned to work since the accident? * Yes No Were you wearing a seat belt? * Yes No What kind of vehicle hit yours? * What kind of vehicle were you in? * If auto accident, were you the...? * Driver Passenger Pedestrian If passenger, were you sitting in the...? * Front Right Rear Left Rear OtherOther Did your vehicle hit other vehicle(s)? * Yes No Estimated speed of your vehicle at impact? (in MPH) Was your vehicle hit by another vehicle(s)? * Yes No Estimated speed of other vehicle at impact? (in MPH) Did your car strike the other(s) involved? * Yes No Did the other car strike yours? * Yes No Undetermined Vehicle You Were In Driver * Insured * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Auto Insurance Co. * Insurance Co. Address * Insurance Co. Address Insurance Co. Address Insurance Co. Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Adjuster * Phone * Policy # * Claim # * Other Vehicle Driver * Insured * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Auto Insurance Co. * Insurance Co. Address * Insurance Co. Address Insurance Co. Address Insurance Co. Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Adjuster * Phone * Policy # * Claim # * Did you require post-accident hospitalization? * Yes No Check the symptoms you have noticed since the accident. * Headache Neck pain Neck stiff Sleeping problems Back pain Nervousness Tension Irritability Chest pain Dizziness Head seems too heavy Pins & needles in arms Pins & needles in legs Numbness in fingers Numbness in toes Shortness of breath Fatigue Depression Light bothers eyes Loss of memory Ears ring Face flushed Buzzing in ears Loss of balance Fainting spells Loss of smell Loss of taste Diarrhea Feet cold Hands cold Stomach upset Constipation Cold sweats Fever OtherOther Symptoms other than above Immediately after the accident, how did you feel? * How did you feel the next day? * Have you lost days of work? * Yes No Dates Name of your Insurance Company involved * Name of person at your Insurance Company responsible for injuries * Have you been contacted by an Insurance Adjuster or Company Representative regarding this claim? * Yes No Do you have an attorney who has advised you in this case? * Yes No Name Address of Attorney Address of Attorney Address of Attorney Address of Attorney City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone No. Patient's Signature * Date *
