Vehicle Wreck Intake Form

Today's Date:*
Your Name:*
Your Address:*
Street Address City State ZIP Code
Your Phone Number:*
Your Email Address*
How did you hear about Anderson, Cummings & Drawhorn?:
- Google Search
- Referring attorney
- Former client
- Friend
- Social media (Facebook, Twitter, Linked In, etc.)
My relationship to the Injured Person is that:
- I am the Injured Person
- I am the spouse of the Injured Person
- I am the parent or guardian of the Injured Person
- I am the adult child of the Injured Person
- I am a friend of the Injured Person
Injured Person's Full Name:
Injured Person's Date of Birth:
Injured Person's Driver's License and State of Issuance:
Name, Phone Number and Relationship of Emergency or Alternate Contact:
Date of the Incident:
Time of the Incident:
: Hours
Minutes
AM/PM
State Where Incident Happened:
- Texas
- Oklahoma
- New Mexico
- Louisiana
- Arkansas
County Where Incident Happened:
Location of the Incident:
Did the Police, Sheriff, DPS or other Law Enforcement come to the scene of the wreck?:
- Yes
- No
- I don't know
What Law Enforcement agencies came to the scene?:
Was a crash report made?:
- Yes
- No
- I don't know
Did Law Enforcement issue any tickets or citations?:
- Yes, the other driver received a ticket
- Yes, I received a ticket
- No tickets were given
- I don't know
Who owned the vehicle the injured person was in at the time of the wreck?:
- The injured person owned the car
- A relative of the injured person owned the car
- A friend of the injured person owned the car
- The injured person was in a commercial vehicle, such as a work vehicle
- The injured person was in a cab, Uber, Lyft or some public transportation
Address of the owner of the vehicle in which the injures person was riding at the time of the wreck:
How many vehicles were involved in the wreck?:
- It was a single-car wreck
- 2 vehicles were involved in the wreck
- 3 vehicles were involved in the wreck
- 4 or more vehicles were involved in the wreck
What were the Weather Conditions at the time of the wreck?
- Clear skies
- Dry roads
- Overcast
- Raining
- Foggy or smoky
- Other
Other weather conditions:
What were the Road Conditions at the time of the wreck?:
- No traffic
- Light traffic
- Medium traffic
- Stop-and-Go bumper to bumper traffic
- Construction zone
Was alcohol or drug use involved in this wreck:
- None to my knowledge
- Yes, the other driver had consumed
- Yes, I had consumed alcohol or drugs
- Yes, the injured party had consumed alcohol or drugs
- I don't know if alcohol or drugs were involved in this wreck
Where was the first point of impact on your vehicle?:
- Hit squarely on the rear
- Hit the back bumper driver's side
- Hit the back bumper passenger's side
- Front of my car dead center
- Front corner of my car driver's side
- Front corner of my car passenger's side
- Driver's side of my car
- Passenger side of my car
Where was the first point of impact on the At Fault vehicle?:
- Dead front and center of the other car
- Front driver's corner
- Front passenger corner
- Rear of the other car
- Drivers side of the car
- Passenger side of the car
- There was no contact by the at fault vehicle
Describe the wreck, who did what, where they came from, etc. in detail:
What specifically did the At Fault Driver do that makes you feel they were at fault?:
Did you hear the At Fault Driver say anything about the crash?:
Was the At Fault Driver on their phone at the time of the wreck?:
- Yes
- No
- I don't Know
How many passengers besides the Injured person were in the Injured Persons vehicle?:
- No one else, the Injured Person was alone
- Injured Person and 1 other passenger
- Injured Person and 2 other passengers
- Unable to determine
Were there any witnesses? If so, do you know their names or contact info?:
Color, make and model of the At Fault car, if known:
How many people were in the At Fault vehicle?:
Were there any Skid Marks our gouges left in the road?:
- None. There were no skid marks left on the ground
- Yes. There were skid marks left on the ground
Photographs and Video: Check all that you have or have access to:
- I have no photos
- I have property damage photos
- I have scene of crash photos
- I have photos of the skid marks
- I have photos of the traffic signals and signs where the crash happened
- I have photos of cuts, scars, bruises or medical treatment
- A friend or relative of mine has more photographs
Upload: Photographs and/or Video:
Drop files here or
Max. file size: 50 MB.
Do you want us to hire a photographer to take photos of anything?
- No, there is nothing to photograph at this time
- Yes, the vehicle has not been fixed yet and ti is worth photographing
- No, don't hire anyone, I will either take photos myself or have a friend do it
- Yes, I think if we took photos of the scene it would help prove our case
- Yes, please take photos of my car and the scene
Who else may have any photographs or evidence to help prove your case?
What other evidence might exist that we should try to obtain to help prove your case? Who has it, what is it, how do we get it?
DETAILS ABOUT YOUR INJURIES
Did Fire/Ambulance/Rescue come to the crash scene?
- Yes, and they checked me out and left
- Yes, and they checked out other people and left
- Yes, they took me to the hospital
- Yes, they took another person to the hospital
- No. Fire/Ambulance/Rescue did not come to the scene of the crash
Did you go to a hospital as a result of this car crash?
- Yes, I went to the hospital the same day as the crash
- Yes, I went to the hospital the next day after the crash
- Yes, a few days later I went to the hospital
- Yes, it was quite a while later, but I had to go to the hospital because of this car crash
- No, I have not needed to go to a hospital because of this car crash
Which hospital?
Check the boxes for all injuries you received from this crash
- No Injury
- Fractures/broken bones
- Head Injuries, cuts, scrapes, bumps
- Loss of consciousness for even a second
- Headaches
- Jaw pain or clicking
- Feeling dizzy
- Blurred vision
- Short term memory loss
- Neck pain
- Shoulder pain
- Arm pain
- Numbness or tingling going down my arm or arms
- Hand or wrist pain
- Numbness tingling in my hands or fingers
- Shooting pain in shoulders, arms, elbows, wrists, hand or fingers
- Mid back pain
- Seat belt or shoulder belt bruising or scrapes
- Air bag burns to my face, arms or hands
- Low back pain
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- Ankle pain
- Foot pain
- Bruises
- Cuts that will leave a scar
- Road rash
Describe any and all injuries you relate to this car crash:
What doctors or health care providers have you seen for injuries from this crash?
Please tell us all the doctors, chiropractors, x-ray, MRI facilities and so forth that you can recall, by name and address, if known. If you have not seen anyone yet, just type None.
Have you been prescribed any medications?
- Yes, the doctors prescribed medications for this
- No, I have not been prescribed any medications
Medications for injuries from this wreck
What medications were you taking on a regular basis before this incident?
Have you lost any time from work as a result of injuries from this wreck?
- Yes, but I have returned to my regular work duties and hours
- Yes, and I have not returned to my regular work duties and hours
- No, I have not lost any time from work
- No, I am retired or not currently employed
Employer name and address:
Job title:
Rate of pay:
Supervisor name:
Check the boxes for prior injuries you have sought treatment for BEFORE this crash:
- None, I have never been treated for any prior injury or illness
- Fractures/broken bones
- Head Injuries, cuts, scrapes, bumps
- Loss of consciousness for even a second
- Headaches
- Jaw pain or clicking
- Feeling dizzy
- Blurred vision
- Short term memory loss
- Neck pain
- Shoulder pain
- Arm pain
- Numbness or tingling going down my arm or arms
- Hand or wrist pain
- Numbness tingling in my hands or fingers
- Shooting pain in shoulders, arms, elbows, wrists, hand or fingers
- Mid back pain
- Seat belt or shoulder belt bruising or scrapes
- Air bag burns to my face, arms or hands
- Low back pain
- Sciatica pain going down my legs
- Shooting pain going down my legs
- Numbness going down my legs
- Hip injury
- Knee injury
- Lower leg injury or numbness
- Ankle pain
- Foot pain
Describe your prior treatment (Who, What, When, Where, Why, etc.):
List all hospitals you have been in over the past 10 years:
Have you ever made any sort of claim before this one? Like a previous car wreck, on-the-job injury, workers compensation, slip and fall, dog bite, or other injury where you were a party?:
- Yes, I have had claims before this one
- No, I have never made any sort of injury claim in my life
Have you had prior Chiropractic care?:
- Yes, I have been to a chiropractor before this incident
- No, I have never been to or seen a chiropractor
Have you ever had prior psychiatric or psychological care or counseling?:
- Yes, I have previously seen or been to a psychiatrist or psychologist before this incident
- No, I have never been to a psychiatrist or psychologist ever in my life before this incident
Have you ever had a Workers Compensation Claim?:
- Yes, I have had a workers comp claim in the past
- No, I have never been hurt on the job, never had a workers compensation claim
DETAILS ABOUT INSURANCE
What is the name of your/injured person’s car insurance company that was in effect in the date of this accident?:
What is your/injured person’s insurance policy number?:
Do you have Uninsured/Underinsured Motorist coverage on your auto policy?:
- Yes
- No
- I'm not sure
Limits of my UM/UIM coverage:
Do you have Personal Injury Protection or Medical Payment coverage on your auto policy?:
- Yes
- No
- I'm not sure
Limits of my PIP or MedPay coverage:
Which insurance companies have contacted you so far?:
- None. No insurance company has contacted me
- My insurance company has contacted me
- The at fault driver’s insurance company has contacted me
- An investigator or some other insurance company has contacted me
Name of At Fault Driver, if known:
Address of At Fault Driver, if known:
At Fault Driver’s License Number, if known:
Who is the At Fault Driver’s Insurance Company, if known?:
What is the At Fault Driver’s Insurance Company Claim Number, if known?:
The owner of the vehicle that was at fault is:
- The same person as the driver
- Known to me and his/her name is in the space below
- I don’t know who owner was
Name of the owner of the vehicle that was at fault:
Do you have Health Insurance?:
- No, I have no health insurance of any kind
- Yes, I have health insurance
My Health Insurance Carrier is:
Are you on or eligible for Medicare?:
- No, I do not have Medicare
- Yes, I have Medicare
Are you on Medicaid?:
- No, I do not have Medicaid
- Yes, I have Medicaid
Are you on Disability Insurance?:
- No, I do not have Disability Insurance
- Yes, I have Disability Insurance
Is there a claim for Property Damage to your vehicle?:
- No, because there was no damage to fix
- No, because it was not my vehicle that was damaged
- No, because the Property Damage claim has been resolved
- Yes, the Property Damage Claim is not resolved yet
Have you given a Recorded Statement?:
- No, no one has taken a recorded statement from me
- Yes, I gave a recorded statement to my insurance company
- Yes, I have given a recorded statement to the other party’s insurance company
- Yes, I have given a recorded statement but I don’t know who it was
- Other
Recorded Statement Details
PERSONAL DETAILS
What is your marital status?:
- Single
- Married
- Divorced
- Widow
How many children do you have?:
- None
- One minor child
- Two minor children
- Three or more minor children
- One adult child
- Two adult children
- Three or more adult children
Have you filed your income tax returns in the past?:
- No. I have not filed tax returns in the past 5 years
- Yes, I have filed my tax return for 5 years or more
- Yes, but less than 5 years
What is the highest level of education you have achieved?:
- Some High School
- Graduated High School or equivalent
- Some College
- Associates Degree
- Bachelors Degree
Have you ever been in the military?:
- Yes, I have been in the military, or I am still in the military
- No, I have never been in the military
Have you ever had your driver’s license suspended or revoked?:
- Yes, I have had my driver’s license suspended or revoked, now or in the past
- No, my driver’s license has never been suspended or revoked
Have you ever been convicted of a crime?:
- No, I have never been convicted of a crime
- Yes, I have been convicted of a crime
Are you thinking about filing for Bankruptcy now or in the future?:
- Yes, I am considering filing bankruptcy now or in the future
- No, I have no reason to file bankruptcy now or in the future
Have you ever hired a lawyer before this claim?:
- No, this is the first time I’ve hired a lawyer
- Yes, I have had prior accident or injury cases
- Yes, I have had prior workers compensation cases
- Yes, Bankruptcy
- Yes, Divorce
- Yes, Criminal
- Yes, Other
Past hired lawyer details:
Have you consulted with other attorneys about this case?:
- No. Anderson & Cummings is the first attorney I have consulted
- Yes, I consulted with the below attorney
Do you have any other pending injury claims that are going on now?:
- No, I have no other claims for injuries going on now
- Yes, I have another injury claim that is going with another attorney
Is there anything else you think we should know about you or your claim that has not been covered above?
Email
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Vehicle Wreck Intake Form

Vehicle Wreck Intake Form

DETAILS ABOUT YOUR INJURIES

DETAILS ABOUT INSURANCE

PERSONAL DETAILS