18-WHEELER 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 Separated Divorced Widowed Date of Birth * MM DD YYYY Social Security Number (SSN) * Secondry Contact Person's Name * Secondary Contact Person's Relation to You * Secondary Contact Person's Phone # * (###) ### #### Date of Collision * MM DD YYYY Time of Collision * Hour Minute Second AM PM Type of Collision * Rear End Head On Sideswipe Rollover Other Description of Collision * Road Condition * Clear / Dry Slick - Water Slick - Ice Mud / Dirt / Debris Other Obstruction Weather * Sunny/ Clear Cloudy Rain Snow Hail / Sleet Fog High Wind Client's Drivers License Number and Issuing State * Client's Vehicle * Provide the Year, Make, Model, Vin Number, and License Plate of Client's Vehicle. Do you have Uninsured / Underinsured ("UM/UIM") Coverage * Do you have Personal Injury Protection ("PIP") Coverage * Client's Insurance Carrier / Provider * Your Insurance Carrier / Provider Policy Number * Has a Claim been filed through Client's Insurance Carrier / Provider? * Yes No Unsure Your Insurance Claim Number for this Collision * Adverse Driver Information * Provide the Name, Address, Phone Number, and other information available. Adverse Driver's Drivers License Number and Issuing State * Adverse Driver's Vehicle * Provide the Year, Make, Model, Vin Number, and License Plate of the Adverse Driver's Vehicle. Adverse Driver's Insurance Carrier / Provider * Adverse Driver's Insurance Policy Number * Has a claim been filed through the Adverse Driver's Insurance Provider / Carrier? * Yes No Unsure Adverse Driver's Insurance Carrier / Provider's Claim Number for this Collision * Detail all bodily injuries sustained from this Collision. * Were you transported to a hospital via EMS / Ambulance? * Yes No Detail your medical treatment since the Collision * Include the name of the facility and their address. Do you have Health Insurance? * Yes No Health Insurance Provide the Name of your Health Insurance Carrier and Policy Number. Was there a Police Response to this Collision? * Yes No Provide the name of the Responding Law Enforcement Agency and Report Number Have you spoken to any insurance company regarding this Collision * Yes No Do you own the vehicle involved in the Collision? * Describe the damage to the vehicle you were driving or a passenger in. * Location. of the vehicle you were driving or a passenger in. * Were there any passengers in your vehicle? * Provide their name, phone number, address, and seating position within the vehicle. Witnesses * Provide the name and contact information for any known witnesses to this Collision Have you had to or do you estimate you will have to miss work? * Job Title, Employer Name, and Rate of Pay * Do you have any photos of the scene of the collision, damages to your vehicle, or your bodily injuries? * Yes No Previous Attorney in this Matter? * Have you consulted, spoken to, or hired any other attorney(s) to represent you for this collision? Referral Source * 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.
