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Participant ID or SSN
Date of Birth
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Accident/Injury Questionnaire
Contact Info
Name
Phone
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Email
Basic Info
Injured person
Accident Information
Date of the accident/injury
Please describe how the accident/injury occurred
Please describe where the accident/injury occurred
Please select what body part(s) were involved in the accident/injury
Head
Neck
Left Shoulder
Right Shoulder
Left Upper Arm
Right Upper Arm
Left Lower Arm
Right Lower Arm
Left Hand
Right Hand
Chest
Upper Back
Lower Back
Upper Abdomen
Lower Abdomen
Hip
Groin
Left Upper Leg
Right Upper Leg
Left Knee
Right Knee
Left Lower Leg
Right Lower Leg
Left Foot
Right Foot
Did the accident/injury happen while you were working?
Yes
No
Accident While Working
Has the employer been notified?
Yes
No
Date the employer was notified
Please describe the circumstances of the accident/injury
Was the accident/injury the result of a motor vehicle accident?
Yes
No
Vehicle Accident
Were you the
Driver
Passenger
Pedestrian
Driver's name
Policyholder's name
Auto insurance company
Auto insurance phone #
(
)
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Claim #
Number of vehicles involved
Was a traffic citation issued?
Yes
No
To whom?
Is there medical coverage available through the automobile insurance policy?
Yes
No
How much?
$
Is there other insurance coverage (other than listed above) available for the accident/injury?
Yes
No
Other Insurance Company
Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip
Phone
(
)
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×
Is another party liable for the accident/injury?
Yes
No
Liable Party
Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip
Phone
(
)
-
×
Have you already retained an attorney or do you intend to retain one?
Yes
No
Attorney
Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip
Phone
(
)
-
×
Additional information you would like us to know about this accident/injury
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