General Information

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Name: Date:

Address:

City: State: Zip Code:

Description of Injury:

Please Check Box(s) that apply to Your Injuries:

Soft Tissue
Radiating Pain
Disc Injury

Bruising
Broken Bones
Scarring

Lacerations
Loss of Consciousness
Head Injury

Headaches

Treatment Since Accident:

Soft Tissue
Radiating Pain
Disc Injury

Ambulance
Emergency Room
Hospital Admission

Medical Doctor
Naturophath
Chriopractor

Surgery
Future Surgery

How did you Hear about us?

Prior Accidents(s) Date(s):

Prior L&I claims(s) Date(s):

Other Medical History:

Family Doctor:

Education:

Children Name\ages:

Driver's License Number:

Accident Information

Date of Injury:

Time of Day:

Location of Accident (Name of street, road or highway)

(Intersection)

(County)

(City)

(Other)

Direction
North
South
East
West

What was your posistion in the Accident?
Driver
Passenger
Pedestrian
Motorcyclist
Bicyclist

If applicable were you wearing a seatbelt? yes no

Who investigated the Accident?
Police
State Patrol
County
City
No Investigation

Case Number: Officer's Name:

Were citations issued? yes no

If yes who recieve What violation?

Number of vehicles involved:

Number of people in Your vehicle: Your Speed:

Number of people in other vehicle: Other speed:

Accident Description

Had you consumed any Alcohol/ Drugs/ Medication 24hrs prior to the accident? yes no

If yes, how much?

Insurance/ Defendant Information

Name of Defendant

Address:

City: State: Zip Code:

Insurance Carrier: Policy/ Claim No.

Name of Insurance Adjuster:

Address:

City: State: Zip Code:

Phone

Acting Within Scope of Employment: yes no

Company Name:

Your Insurance Infromation

Auto Insurance Carrier

Policy No.

LIABILITY UM/UM PIP

Policy Holder Name (if different than self):

Name of Insurance Adjuster Claim No. Address:

City: State: Zip Code:

Phone

Medical Insurance

Plan No. Address:

City: State: Zip Code:

Phone

DSHS yes no

Acting Within Scope of Employment: yes no

L&I Claim No.:

Witness Information

Name of Witness Phone Address:

City: State: Zip Code:

Property Damage Information

Is Property Damage an Issue? yes no

If so, has your Property Damage been Resolved: yes no

If so, by who?

Your vehicle description: Make\Model

Your property damage amount: $ Was your vehicle towed? yes

If so, by who?

Others vehicle description: Make\Model

Their property damage amount: $ Was their vehicle towed? yes no

If so, by who?

Employment Info.

Current Employer

Address:

City: State: Zip Code:

Phone No. Supervisor’s Name

Title of Your Position Salary (yearly)$ Monthly $

Description of Duties

Has accident caused you to lose time from work? yes no

Employer at time of accident, if different from above

Address:

City: State: Zip Code:

Phone No. Supervisor’s Name

Title of Your Position Salary (yearly)$ Monthly $

Description of Duties

Has accident caused you to lose time from work? yes no

Treatment Resulting From Current Accident

Ambulance Phone