Accident Interview Form

ACCIDENT INTERVIEW FORM

Accident Interview Form

Today’s Date:______

Date of Accident:______201___ Time of Accident: ______am / pm

Referred By (eg: Google, friend, doctor): ______

Client:______

Address:______

______Postal Code______

Date of Birth:______Age:______

Phone: (H)______(W)______Email: ______

Marital status: ______Name of spouse:______

Do you have child(ren)?______Child(ren)’s name(s) and birthdates: ______
______

NOTES TO CLIENT

1) PLEASE DO NOT TALK TO WRONGDOER’S ADJUSTER (who is looking for information only to help the wrongdoer) – INSTEAD, PLEASE JUST OBTAIN THE ADJUSTER’S NAME, COMPANY NAME, PHONE NUMBERS, CLAIM NUMBER and provide Deborah with this information.

2) YOU MAY BE UNDER SURVEILLANCE – NOTIFY US IF YOU OBSERVE THIS, TO DISCUSS.

YOUR MOTOR VEHICLE INSURANCE COMPANY (your insurer)
(if you were a passenger, this is your driver’s insurance company)

Name of your insurer (eg. Intact): ______
Name of individual adjuster at your insurer:______

Adjuster’s phone number/email/fax number: ______
Your policy number and claim number:______

YOUR MOTOR VEHICLE
(if you were a passenger, this is your driver’s motor vehicle)

Year, make, model and color: ______
Name of registered owner:______

Dollar value of damage sustained in accident (also, please attach estimate/repair documents, if available): $______
Occupants of your vehicle at the time of the accident:______

WRONGDOER’S MOTOR VEHICLE

Year, Make, Model and Color of wrongdoer’s motor vehicle: ______

License Plate #:______

Motor vehicle VIN #:______

Describe damage to wrongdoer’s vehicle:______

THE WRONGDOER’S MOTOR VEHICLE INSURANCE COMPANY

Name of the wrongdoer’s insurance company (eg. Intact): ______

Name of adjuster at wrongdoer’s insurance company:______

Wrongdoer’s insurance adjuster’s phone number/email/fax number: ______

Wrongdoer’s insurance adjuster’s claim number:______

WRONGDOER DETAILS

If you have photographed the wrongdoer’s driver’s license and vehicle insurance card, please email Deborah the photographs. If you have a copy of the police Collision Report Form, please email that to Deborah. Additionally, please fill in the following details about the wrongdoer that you have written down at the accident scene:

Name of the wrongdoer driver: ______

Address of wrongdoer driver:______
Telephone number:______

Name of owner of the wrongdoer’s vehicle: ______
Address of owner of wrongdoer’s vehicle:______
Telephone number:______

Relationship of owner and driver, if you are aware of this:
eg. Married couple, father/daughter, business/employee: ______

Wrongdoer driver’s Driver License number: ______

Insurance Card:
Name of wrongdoer’s insurance company and adjuster ______

Policy number ______

Names, addresses and telephone numbers of witnesses: ______
______

SCENE OF ACCIDENT

Location:______

Weather:______Weather:______Street Lights: Yes / No

Type and Condition of Road______

Hill, curve, bridge, etc.:______

Traffic Lights or Signs______

Marked Traffic Lanes:______

Any Charges Laid:______Result:______

List any medications, alcohol or drugs taken by you within 24 hours of the accident (this is confidential): ______

EVIDENCE

Any admission made or statements signed:______

Names / Phone Numbers of Witnesses______

______

DESCRIPTION OF ACCIDENT

______

______

INJURIES

Nature of Injuries:______

______

______

Were you examined by paramedics at the accident scene?______

Were you transported to hospital by ambulance from the accident scene?______

Hospitalized: Yes / No If yes, which hospital and what dates:______

______

Please list and describe all prior vehicle related accidents and injuries sustained, if any:

______

Please list all prior accidents and injuries sustained from sports, activities, falls, etc., if any:

______

NAME / FACILITY OF TREATING PRACTITIONERS

Attending Physician:______

Family Physician:______

Chiropractor:______

Physiotherapist:______

Massage Therapy:______

Other / Specialists:______

Other / Specialists: ______

Restriction of Activities:______

______

Previous Health and Physical Condition:______

Previous Injuries:______

EMPLOYMENT / WAGE LOSS INFORMATION

Will you be advancing a wage loss claim? Yes / No / Don=t Know Yet

Employer:______

Address:______

Fax: ______Phone:______Postal Code______

Job Title:______Length of time at this job:______

Dates Absent from Work:______

Wages / Salary:______Full or Part-time:______

Employment Benefits:______

Benefit Details: Group Plan No.:______I.D No.:______

SPECIAL DAMAGES (PLEASE FORWARD SUBSTANTIATING RECEIPTS & INVOICES)

Loss of Income or Opportunity to Work______

Clothing and Personal Articles:______

Household Help:______

Taxi / Train / Bus Fares:______

Out of Pocket Expenses: (i.e. prescriptions, over the counter medications)______

______

Other:______

______

Please provide: Personal Health Number: ______

Private Health Insurance: ______

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