Greensboro Car Accident Intake Form

Car Accident Intake

From all of us at Garrett, Walker, Aycoth & Olson, thank you for giving us the opportunity to help you with your car accident. Please complete the form below so we can better assist you with your case. Thank you.

CLIENT CONTACT INFO

Name *

Name I prefer to be Called: (If Not Legal Name - Optional)

Address *

Country

City

State

Zip code

Date of Birth *

Primary Phone Number: *

Phone Number #2 (optional)

Email *

Driver's License Number *

If you can't reach me, please call

At the Following Phone Number

ACCIDENT DETAILS

Date of Accident *

How Did the Accident Happen? *

State Driver's License Issued (ie North Carolina / NC) *

Describe the Movement of your Body Upon Impact *

Did any part of your body make contact with a part of the vehicle at the time of contact? *

Yes

Don't Know

Did you get Medical Treatment? *

Yes

If Yes, please complete information at the bottom of this form including physician information and medications prescribed.

Do you have Medical Insurance? *

Yes

If Yes, Who Is Your Carrier?

Medical Insurance Carrier (If no insurance, put N/A) *

Medicare? *

Yes

Medicaid? *

Yes

Have you ever served in the United States Military? *

Yes

Former Military Service Members, Thank You for Your Service!

What type of Vehicle were you In? *

Car

Motorcycle

Truck

Other

Were you the Driver or the Passenger? *

Driver

Passenger

Did the Police Write Anyone a Ticket? *

Yes

Don't Know

If they wrote a ticket, Who Did They Write the Ticket For? (check all that apply)

My Driver

Driver of Another Car

Someone Else

Was there Property Damage OVER $1,000 (NOT including motorcycles or bumpers)? *

Yes

Do you have auto insurance? *

Yes

If so, who is your Carrier?

If you don't have auto insurance, does any member of your household have auto insurance?

Yes

Does the Coverage Include Medical Payments ("MEDPAY")?

Yes

Don't Know

If so, How Much?

Has the insurance company made any settlement offers? *

Yes

If yes, When?

How much was the Offer?

If a person referred you, who can we thank?

THANK YOU FOR TRUSTING US WITH YOUR LEGAL NEEDS

Physician Info

Practice Name

Physician Name

Pratice Address

Apt, suite, etc.

Country

City

State

Zip code

Practice Phone Number

If you saw more than One Physician, Please List the Other Physicians and their Practices Here

Medications

Please list all medications prescribed and duration of use:

Please Upload Important Documents Here:

File Upload

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