Auto Accident Pre-Screening

Personal Injury Intake Questionnaire

Once you have properly submitted the personal injury intake form, you will receive a confirmation of submission. If you do not receive a confirmation on the next page, the form was not completed properly. Please review your form for errors highlighted in red, correct the error(s), then re-submit.

Health Insurance Information

Employment History

Current Employer Information

(e.g.: Mon 9-5)

Your Automobile Insurance coverage

If you don't know the answer to a question, write "unknown". Please obtain a copy of your insurance policy declaration page along with any riders and bring them with you to your consultation.

Incident Facts

(E.g.: City, Country, State, Street/Cross-street)

Vehicle Occupants

Property Damage

Bodily Injuries

How have your injuries changed your lifestyle?


Doctors and/or Facilities

Please Provide Information Regarding Doctors and/or Facilities That Have Treated You Since This Incident.

Other Helpful Information

Click or drag files to this area to upload. You can upload up to 50 files.
By agreeing to this disclaimer, you represent that the information provided by you in this document is accurate and true to the best of your knowledge.