Intake Form - Auto Accident

for Your State

This Auto Accident Intake Form is for use by an attorney when gathering information from a client regarding an automobile accident. This form contains a broad scope of questions including contact and insurance company information for both drivers and any medical treatment which was necessary. This form is for use in your state.

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with every order
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This Auto Accident Intake Form is for use by an attorney to gather information from a client regarding an auto accident. This form contains a broad scope of questions regarding the client including full name and all contact information, employment and health insurance information and prior medical treatments. This Intake Form also includes detailed information regarding the accident itself including date, time and brief description, vehicle description and the names of any witnesses. When gathering information about an accident it is important that all pertinent information be documented.

This Intake Form for an Auto Accident includes the following:
  • Client Name and Referral: Sets out the name of the client and how he or she was referred (television commercial, newspaper, yellow pages);
  • Client Information: Client’s full name along with any aliases, address, phone number, date of birth, detailed physical information, criminal record, nearest relative to contact information and if client has taken bankruptcy;
  • Employment: Client’s employment information at the time of the accident and if employer was notified;
  • Health Insurance/Prior Claims: Client’s health insurance information and if any prior insurance claims or medical treatments have occurred;
  • Accident Information: Detailed information regarding the accident including the date, time and location, road and weather conditions, description of what happened, vehicle description and if estimates of damages have been received;
  • Adverse Information: Information regarding the other driver including name, contact and insurance company information;
  • Medical Treatment: Information regarding medical treatment sought after the accident and any follow-up care or prescriptions given;
  • Witnesses/Other Information: The name and phone numbers of any witnesses to the accident and other information which may be important for client’s case.

Protect your rights by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Information
  2. Auto Accident Client Intake Form
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
Number of Pages5
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28061
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.

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