Injury Questionnaire - Drivers Legal Defense

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- Step 1 of 11

Information about you

Your name *

First

Last

Date & Time of your accident *

Date

Time

Sex

Male
Female
Other

Date of Birth *

Telephone Number

Are You Married? *

What Is Your Spouses Full Name?

Social Security Number: *

(If none please indicate so)

Your Driver's License Number *

(If none or inapplicable please indicate so)

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Car Insurance/Accident Claim Information

Please skip this section if you were not the driver of the vehicle.

Your Car Insurance Company *

(If none or inapplicable please indicate so)

Car Insurance Policyholder's Name

(If somebody other than yourself)

Your Car Insurance Policy Number *

(If none or inapplicable please indicate so)

Claim Information Relating To This Accident.

Your Car Insurance Accident Claim Number *

If none or inapplicable please indicate so

Your Car Insurance Accident Claim Adjuster's Name

Your Car Insurance Accident Claim Adjuster's Phone Number/Extension

Vehicle Owner Information

Please skip this section if you were not the driver of the vehicle.

Was the vehicle involved in the accident your own?

Yes, the vehicle is registered to me
No, the vehicle is registered to someone else

Who is the registered owner of the vehicle you were in at the time of the collision?

What is your relation to the registered owner of the vehicle you were in at the time of the collision?

Please provide the contact information for the registered owner of the vehicle you were in at the time of the collision:

address/phone/email/etc.

Personal Health Insurance

Please provide your personal insurance information

Your Health Insurance Provider *

If none please indicate that

Your Health Insurance ID# *

If none please indicate that

Health Insurance Policyholder Name

(If somebody other yourself)

Are you a Medi-Cal beneficiary? *

Mark "NA" if the info is the same as the previous question.

If so, what is your Medi-Cal ID#? *

Mark "NA" if the info is the same as the previous question.

Have You Received Medical Treatment Following The Collision? *

Hospital/Facility/Doctor's Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Hospital/Facility/Doctors Name (#2)

Address (#2)

Address Line 1

Address Line 2

City

State

Zip Code

What type of treatments did you receive from these facilities?

Please include as much information as possible

Information about your accident

Location of accident *

Please input a cross street or exact address. If the accident occurred on a freeway please put which freeway you were driving on, which direction, and the nearest exit.

What was the purpose of your trip at the time of the accident? *

(driving home, to work, to the store, etc.)

Were you: *

Driver
Passenger (front seat)
Passenger (back seat)

How many total people were in your vehicle including yourself?

Were you wearing your seatbelt?

What direction were you heading?

North
South
East
West

What direction was the other vehicle heading?

North
South
East
West

What side were you struck from?

Behind
Front
Left side
Right side

How many total vehicles were involved in this collision including your own? *

What is the year/make/model of the car you were in at the time of the collision? *

What was the approximate speed the car you were in at the time of the collision?

What is the VIN of the car you were in at the time of the collision?

What is the license plate number of the car you were in at the time of the collision?

Was there a child car seat in the car you were in at the time of the collision? *

(If yes please indicate how many car seats there were)

What is the present location of the car you were in/driving? *

(If unknown please indicate so, if at a body shop please provide the shop's name)

What is the present condition the car you were in/driving? *

(Is it drivable? Do you think it is totaled? Please describe the damages of your vehicle.)

Other Party Information

What is the name of the driver of the car you believe caused the accident? *

Put unknown if you do not know

What was the approximate speed of the car you believe caused the accident?

What is the year/make/model of the car you believe caused the accident?

What is the VIN of the car you believe caused the accident?

What is the license plate number of the car you believe caused the accident?

What was the car insurance company of the car you believed caused the accident? *

(if the other party was uninsured or did not provide insurance information please indicate so)

What was the car insurance policy number for the car you believed caused the accident? *

(if the other party was uninsured or did not provide insurance information please indicate so)

Information about your accident (continued)

Were you knocked unconscious?

For how long?

Were the police notified? *

What Police Department Responded? *

(If none please indicate so)

What was the Police Report Number? *

(If none please indicate so)

Were there any witnesses? *

Please provide the witnesses names/contact information.

Where did you go after the accident? *

home, emergency room, urgent care, friend's house, etc.

How were you transported? *

ambulance, uber, drove yourself, etc.

Information about your accident (continued)

In your own words, please describe the accident.

We will need a written statement outlining the events that occured in this accident from start to finish.
Please make sure to include the following information:

1. When the accident took place including the time of day.
2. Where exactly the accident took place.
3. Traffic & Weather Conditions.
4. Which lane you were in.
5. Which lane the other party was in.
6. The other party's name as well as describing the interaction you had with them.
Make sure to explain how the entire accident happened from before the collision took place until you left the scene. Please be as detailed as possible, every piece of information is helpful.

In your own words, please describe the accident *

Which parts of your body were injured? (List every body part)

What is the present condition of your pain/injuries?

Did you have any physical complaints before this accident?

Please describe your physical complaints prior to the accident.

Since this injury occurred are your symptoms

Improving
Getting worse
Unchanged

Employment Information

Have you lost time from work as a result of this accident?

What was your occupation at the time of your injury?

What was your last day of work?

Date

Time

When do you plan to resume working, or when did you return to work?

Date

Time

(Leave blank if you have not started working again)

Are you self employed?

Who Is Your Employer?

What is the address of your employer?

What is your employer’s phone number?

When the accident happened, were you working?

Do you carry Workers Compensation Insurance?

At the time of your injury, what was your rate of pay?

$X per day / $X per week / $X per month

What was the value of tips, meal lodging, or other advantages, regularly received?

$X per day / $X per week / $X per month

Did you receive compensation for your injury by your employer or through your workers compensation insurance?

What is the total amount of compensation you received?

$X per day / $X per week / $X per month

Were you paid on a weekly basis for your injuries by your employer / workers compensation insurance?

What was your weekly pay rate?

Have you received any unemployment insurance benefits and/or any unemployment compensation disability benefits (state disability) since the date of injury?

Have you received medical treatment since the injury?

Has your employer or the workers compensation insurance company paid for all of your medical treatment since the injury?

What other people or agencies paid for your medical treatment since your injury?

Please list the names and addresses of doctor(s)/hospital(s)/clinic(s) that treated or examined for this injury, but that were not provided or paid for by the employer or insurance carrier:

What was the date of your last treatment?

Did Medi-Cal pay for any health care related to this claim?

Have you previously filed any other workers compensation claims?

Please provide the case numbers for your previous claims:

Previous Accident(s)

Have you been involved in a car accident before? *

How many accidents have you been involved in previously? *

Were you injured as a result of these accidents? *

What dates did they occur on? *

Did you receive a settlement or file a lawsuit in relation to the previous accident(s)? *

Final Information

If you have any additional documents - please submit them here.

File Upload

Click or drag files to this area to upload. You can upload up to 50 files.

We will need any documentation you have that may pertain to this case. This includes but is not limited to the following:

1. Doctors/ER paperwork.
2. Police report information.
3. Pictures taken at the scene of the accident.
4. Information about the other party involved.
5. Your Insurance information.
6. Witness contact information.