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AME: NAME: PHONE: PHONE: PHONE: OTHER IMPORTANT INFORMATION: CODE CLAIM # MEDICAL TREATMENT: TRANSPORTED TO HOSPITAL: YES NO - AMBULANCE NAME OF HOSPITAL: FOLLOW UP CARE - DOCTOR OR FACILITY? OTHER (PRESCRIPTIONS, PHYSICAL THERAPY, ETC.) WITNESSES: NAME: NES: DRIVEABLE YES NO - TOWED YES NO CURRENT LOCATION OF VEHICLE: PHOTOGRAPHS: YES NO - ESTIMATE DONE: ADVERSE INFORMATION: ADVERSE NAME: ADDRESS: CITY TELEPHONE: INSURANCE COMPANY ADJUSTER: STATE ZIPED: YES NO TIME OF LOSS: WEATHER: LIGHTING POLICE REPORT: YES CHARGE A.M. P.M. NO DESCRIPTION OF ACCIDENT: CLIENT VEHICLE: INSURANCE INFORMATION: COMPANY: COVERAGE: OWNER DRIVER PASSENGER DAMAGES, SIIS, PROPERTY, SSI, ETC.): PRIOR MEDICAL TREATMENT/CARE HOSPITALIZATIONS (LAST 5 YEARS): MAJOR INJURIES MAJOR SURGERIES: ACCIDENT INFORMATION: DATE OF LOSS: SITE: ROAD CONDITIONS: TRAFFIC: CIT: ZIP CODE HEALTH INSURANCE NAME OF INSURANCE COMPANY POLICY NUMBER NAME OF POLICY HOLDER I.D. NO. PRIOR CLAIMS YES NO ANY INSURANCE CLAIMS (SLIP & FALL, AUTOMOBILE, WORK RELATED CLAIM, DOG BIT YOUR EMPLOYER?: YES NO SIIS REPORT MADE?: YES NO IF YES, ON WHAT DATE? B. EMPLOYER'S NAME: ADDRESS: CITY TELEPHONE: C. DUTIES: PAY RATE: HOW LONG EMPLOYED: LOSING TIME? YES NO YES NO STATE JOB TITLE YES NO 4. 5. 6. EMPLOYMENT: A. EMPLOYED AT TIME OF THIS ACCIDENT: YES NO IF YES, DID THIS ACCIDENT HAPPEN WHILE CLIENT WAS IN THE COURSE AND SCOPE OF EMPLOYMENT? YES NO DID YOU REPORT ACCIDENT TO_______________________________________________________________ NEAREST RELATIVE TO CONTACT: ______________________________________ HOME TELEPHONE: ( )_________ OTHER : ( )_________________ BANKRUPTCY__ WEIGHT: ______ R or L HANDED_____GLASSES: _____HEARING: ______EDUCATION: ________ MILITARY ______ LENGTH IN NEVADA________ ARRESTS/CONVICTIONS: ____YES ______ NO IF YES, DESCRIBE: _________ _______AGE: _______________________ PLACE OF BIRTH: _________________________ SSN: _________________ NAME OF GUARDIAN: _________________________________________________ 3. PERSONAL INFORMATION: HEIGHT: _____ _________________________ IS CLIENT A MINOR? YES NO If YES, please provide the following: 2. NAME OF MINOR:_____________________________________________________ DATE OF BIRTH: ____________________ ____________________ STATE: _______________ Zip: _______________ DATE OF BIRTH: _________________ SSN: ________________________ TELEPHONE:( )_________________ CELL:( ) ________________________ FAX:( ) FULL NAME: _________________________________________________ OTHER NAMES KNOWN AS: ______________________________________ ADDRESS: ____________________________________________________________ CITY: _ournal/T.V. Guide Yellow Pages (specify) Doctor/Attorney Prior client Personal Referral Other: __________ DATE OF INTERVIEW: CLIENT INFORMATION client speaks ____English 1. ______ Spanish CLIENT'Sg any document with another party. The purchase and use of this form is subject to the "Terms and Conditions" found at www.FindLegalForms.com AUTO ACCIDENT CASE NAME: Referred by: Television Review Jnot a substitute for legal advice. This form should only be a starting point for you and should not be used without first consulting with an attorney. An attorney should be consulted before negotiatinInformation Auto Accident Client Intake Form Bracketed instructions may be included on this form to assist you in completing it and should be removed before printing. This form is not intended and is