MOTOR VEHICLE ACCIDENT INTAKE FORM Name * First Name Last Name Middle Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone # * (###) ### #### Email Address * Marital Status * Single Married Widowed Separated Date of Birth * MM DD YYYY Social Security Number (SSN) * Secondary Contact Person's Name * Secondary Contact Person's Relation to You * Secondary Contact Person's Phone # * (###) ### #### Type of Collision * Rear-end T-bone Side swipe Head On Date of Collision * MM DD YYYY Time of Collision * Hour Minute Second AM PM Weather at time of Collision * Clear Cloudy Foggy Rain Hail Snow Road Condition * Dry Wet Snow Sleet Debris of Roadway Description of Collision * Passengers in your vehicle. * Provide the name, age, and relation of any and all passengers in your vehicle. Your Driver's License Number and Issuing State * Make, Model, & Year of your vehicle * Do You Have Uninsured / Underinsured ("UM/UIM") Coverage? * Yes - Hazen Law Firm may put my insurance on notice No - I do not have UM/UIM Unsure - Hazen Law Firm may put my insurance on notice I do not wish to involve my insurance unless absolutely necessary Do you have Personal Injury Protection ("PIP") Coverage? * Yes - Hazen Law Firm may handle my PIP Claim Yes - I will handle PIP myself No - I do not have PIP Coverage Unsure Your Insurance Provider / Carrier * Your Insurance Policy Number * Claim Number through your insurance carrier for this Collision * Adverse Driver's Vehicle * Personal Vehicle 18-Wheeler Commercial - Other Unsure Adverse Driver's name, address, phone number/email * Adverse Driver's License Number and Issuing State * Make, Model, & Year of Adverse Driver's Vehicle * Adverse Driver's Insurance Carrier / Provider * Adverse Driver's Policy Number * Claim Number through the Adverse Driver's insurance carrier for this Collision * Was there a Law Enforcement Response? * Yes No Responding Law Enforcement Agency & Report Number * Location of Motor Vehicle Accident * Bodily Injuries * List all areas of your body with injuries including a description of the injuries. Do you have Health Insurance? * List the provider's name and policy number. Were you transported via EMS to a Hospital? * Yes No Medical Treatment since Collision * Have you had to miss work or do you expect to miss work? * Yes - I have had to miss work. No - I have not had to miss work. I may miss work due to my injuries. Witnesses * Please name any witnesses and a contact number for each witness. Communications between you and the At fault driver. * Do you have any photos or video of the Collision? * Yes, I have video or photos in my possession. No, none to my knowledge. Yes, video or photos exist but it is not in my possession. Describe the damages to your vehicle. * Location of your vehicle * Do you own the vehicle involved in this incident? * Simply reply "YES" if you own the vehicle, otherwise name the individual /entity that owns the vehicle. Referral * Thank you! We will be in touch soon to further discuss your case. Please note, that submitting an Intake Form does not create an attorney client relationship.
