Personal Injury Intake

First Name

Responsible party?

Claims Adjuster Name

Have you retained an attorney?

Were you the driver?

Last Name

Other Parties Insurance?

Your Insurance:

Date of Accident

Claim Number:

Claims Adjuster Phone Number

Attorney Name:

Attorney Phone Number:

If passenger where were you sitting?

Were you wearing a seatbelt?

Your vehicle type?

Other vehicle type?

Did your vehicle go off the road?

Other people in car?

Were you reclined?

Were you looking to either side?

Were you aware the accident was about to happen?

Did you lose consciousness?

Do you remember the impact?

What side of your vehicle took the impact?

Was your vehicle drivable?

Was the other vehicle drivable?

Your vehicle estimated speed?

The other vehicle estimated speed?

Were you transported to the emergency room?

Name of emergency room?

I confirm that the information given in this form is true

Thanks for submitting!

serving: Millerburg, Wooster, Loudonville, Berlin, Sugarcreek, Coshocton