Personal Injury Fact Sheet/Personal Injury Interview Form If Injured in an Accident |
Todays date: _________________________________ Plaintiff name: _________________________________ Address: _____________________________________ ____________________________________________ ____________________________________________ Phone Number: _______________________________ Email: ________________________________________ d/o/b: ________________________________________ Soc.. security: __________________________________ Spouse _______________________________________ 2a. Date of Accident: _____________________________ town, county, state: _______________________________ day of week _____________________________________ time: _________________________________ weather _________________________________ Road conditions _______________________________________________________________________ Description of Accident: _________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2b. Operator of Plaintiffs car: _____________________________________________________________ Owner of Plaintiffs car: __________________________________________________________________ 2c Other occupants of Plaintiffs car. ________________________________________________________ 2d Street Plaintiff was traveling on: __________________________________________________________ Direction of travel (ex- North, south, etc.): ____________________________________________________ Nearest approaching road: ________________________________________________________________ 2e Street Defendant was traveling on: ________________________________________________________ Defendant Direction of travel (ex- North, south, etc.): ____________________________________________ Nearest approaching road: ________________________________________________________________ 2f Traffic lights or stop signs in area: _________________________________________________________ 3. INJURIES- NATURE, EXTENT, DURATION _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. PERMANENT INJURIES AND PRESENT COMPLAINTS _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. HOSPITALS- ADDRESS, DATE OF ADMISSION DISCHARGE _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 6- X-RAYS, TAKEN BY: _________________________________ ADDRESS: ____________________________________________________________________________ DIAGNOSTIC TESTS: ___________________________________________________________________ X-ray, MRI DATE _________________________________ RESULTS _________________________________ 7 DOCTOR-NAME _________________________________ ADDRESS PHONE DATES OF TREATMENT: _________________________________ DATE OF REPORTS: _________________________________ 7B. MEDICAL PROVIDER-NAME __________________________ ADDRESS PHONE DATES OF TREATMENT: _________________________________ DATE OF REPORTS: _________________________________ 7C MEDICAL PROVIDER-NAME ADDRESS PHONE DATES OF TREATMENT: _________________________________ DATE OF REPORTS: _________________________________ 8. STILL BEING TREATED? MEDICAL PROVIDER-NAME NATURE OF TREATMENT AND NATURE OF TREATMENT 9. AGGRAVATION OF PRIOR INJURIES BY ACCIDENT, PRIOR DOCTOR 10. Employer Name: __________________________________ Address: ____________________________________________ Job/Position Gross/week Net/week Time Lost Total Wages Lost: _____________________________________________________ 11. IF RETURN TO WORK: _________________________________ Current Employer Name: _________________________________ Address: _________________________________ Job: _________________________________ ______________ Gross/week Net/week 12- OTHER LOSS OF INCOME, EARNINGS 13. Medical bills, Doctor Amount unpaid Paid hospital bills, medicine, etc. Total medicals (As of ________): _________________________________ 14. OTHER OUT OF POCKET EXPENSES and OTHER LOSSES 15. Relevant Documents: __________________________________________________________________ Police Report: _____________________________________________________________________________ Declaration Sheet: __________________________________________________________________________ Hospital Bills: ______________________________________________________________________________ Hospital Records: ___________________________________________________________________________ Medical Bills and Records: ____________________________________________________________________ Photographs of Accident Site: __________________________________________________________________ Photographs of Damage to Plaintiffs car: __________________________________________________________ Photographs of Damage to Defendants car: ________________________________________________________ Photographs of Injuries, scars, cuts: _______________________________________________________________ Repair damage estimate: _______________________________________________________________________ Other: _____________________________________________________________________________________ 16a defendant name: _________________________________ _________________________________ address: _______________________________ _________________________________ Owner of Def car: _________________________________ address: _________________________________ Type of car: _________________________________ ___________________________ make, year Other occupants of def car 16b Eye witness name: _________________________________ address & phone: _________________________________ 17 Names and addresses of People with Relevant Knowledge Officers of Investigating Police Department: _________________________________ 18. Photographs: _________________________________ _________________________________ If any photographs, videotapes, audio tapes or other forms of electronic recordings, sketches, reproductions, charts or maps were made with respect to anything that is relevant to the subject matter of the complaint, describe: _________________________________ _________________________________ (a) the number of each; (b) what each shows or contains; (c) the date taken or made; (d) the names and addresses of the persons who made them; (e) in whose possession they are at present; and (f) if in your possession, attach a copy, or if not subject to convenient copying, state the location where inspection and copying may take place. ___________ 19. If you claim that the defendant made any admissions as to the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date made; (b) the name of the person by whom made; (c) the name and address of the person to whom made; (d) where made; (e) the name and address of each person present at the time the admission was made; (f) the contents of the admission; and (g) if in writing, attach a copy. 20. If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication. 21. If you have obtained a statement from any person not a party to this action, state: _________________________________ _________________________________ (a) the name and present address of the person who gave the statement; (b) whether the statement was oral or in writing and if in writing, attach a copy; (c) the date statement was obtained; (d) if such statement was oral, whether a recording was made, and if so, the nature of the recording and the name and present address of the person who has custody of it; (e) if the statement was written, whether it was signed by the person making it; (f) the name and address of the person who obtained the statement; and (g) if the statement was oral, a detailed summary of its contents. _____________________________ 22: _________________________________ ___________________________ Violation by Defendant of Motor Vehicle law (i.e. Careless driving or other statute 23. Expert witnesses: _________________________________ 24. Have you every been indicted and convicted of a crime? ______ (This question required by Rules of Court) 25a Plaintiff car ins company: _________________________________ THRESHOLD address: _________________________________ phone: _________________________________ policy # claim # year, make, model collision coverage Who Notified? UM/ UIM coverage 25b Named Insured: _________________________________ _________________________________ _____________________________________ 25c Copy of Dec Sheet: _________________________________ 25d. Plaintiffs private major- medical ex- Blue Cross address: _________________________________ phone: _________________________________ Policy number 26a: Distance between Plaintiff and point of impact when first observed other vehicle and Plaintiffs speed: _________________________________ 26b: distance between Plaintiff and the Defendants vehicle when first observed other vehicle: _________________________________ ___________________________________________________________ 26c: Where Plaintiffs vehicle came to rest and where Defendants vehicle came to rest: _____________________________ ___________________________________________________________ 27: Part of Plaintiffs car hit by Defendants car: _________________________________ ________________________________________________________ Damage to Plaintiffs car: _________________________________ _________________________________ _______________________________________ Property damage estimate: _________________ ___________________________________________________________ 28: Where Plaintiff was coming from and where Plaintiff was going to: _________________________________ ___________________________________________________________ 29. Parts of body hitting car: _________________________________ _________________________________ _____________________ 30. Unconsciousness? _____________________ 31. Skid marks by any car: _________________________________ _________________________________ _____________________ 32. Defendants Ins carrier 33. address: _________________________________ phone: _________________________________ 34. adjuster: _________________________________ 35. Policy limits: _________________________________ claim #: _________________________________ 36. When did you apply your brakes?: ___________________________ _________________________________ _____________________ 37. How fast were you going?: _________________________________ _________________________________ _____________________ 38. How fast was the Defendant going?: _________________________________ _________________________________ _____________________ 39. Describe the position of each car at the point of impact, giving distance from curb, lines, streets or other landmarks?: _________________________________ _________________________________ _____________________ 40. Alcoholic beverages or medication within 12 hours before accident? _______ 41. Prior accidents involving injury in which you received an insurance settlement or suit was started? (Including workers compensation)? Prior car accidents with only property damage? _____________________ 42. Negligent actions by Defendant: _________________________________ _________________________________ 43. What else did you tell police? _____________________ 44. Set forth the names of insurance agents and other individuals you discussed the case with an what did you say? _____________________ 45. Please prepare a Diagram of the accident site _____________________ 46. Are you receiving Medicare/ Medicaid? ___________ Are you receiving SSI? ___________ Is there anything else important? ___________________________ ___________________________________________________________ ___________________________________________________________ Documents to be supplied to attorney & in his possession: Police Report: _________________________________ Declaration Sheet: _________________________________ Medical/ Hospital Bills and Records: _________________________________ Photographs of Accident Site: _________________________________ Photographs of Damage to Plaintiffs car: ___________________________ Photographs of Damage to Defendants car: _________________________________ Photographs of Injuries, scars, cuts: _________________________________ Repair damage estimate: _________________________________
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Monday, October 17, 2011
Personal Injury Fact Sheet/Personal Injury Interview Form If Injured in an Accident
