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Auto Accident Intake
First Name
Responsible party?
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Claims Adjuster Name
Have you retained an attorney?
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Were you the driver?
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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?
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Were you wearing a seatbelt?
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Your vehicle type?
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Other vehicle type?
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Did your vehicle go off the road?
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Other people in car?
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Were you reclined?
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Were you looking to either side?
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Were you aware the accident was about to happen?
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Did you lose consciousness?
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Do you remember the impact?
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What side of your vehicle took the impact?
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Was your vehicle drivable?
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Was the other vehicle drivable?
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Your vehicle estimated speed?
The other vehicle estimated speed?
Were you transported to the emergency room?
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Name of emergency room?
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