Auto Intake

NAME OF INJURED PERSON*

Sex*

Male
Female

SPOUSE/GUARDIAN*

MAILING ADDRESS*

CITY*

STATE*

ZIP*

Email*

Phone*

DOB*

SSN*

Work

Cell

ALTERNATE CONTACT: NAME

First Last

Phone

How did you find us?*

Referral
TV AD
Google/Search
Bus/Billboard AD
Yellow Pages AD
Other

Who Referred You?

How?

ACCIDENT INFORMATION

Date of Accident*

Time*

: HH

MM

Place of Accident*

ACCIDENT DESCRIPTION*

WHERE IS YOUR PAIN?*

POLICE PRECINCT*

ACCIDENT #*

Do you have photographs of the vehicle, location or injuries?

YES
NO

Please attach photos if able or send them to us later.

Drop files here or

Witness 1 Name*

Witness 1 Address*

Witness 2 Name

Witness 2 Address

Identity of the vehicle you occupied or operated at the time of the accident:

Owner's Name*

First Last

Plate #*

Make*

Model*

Year*

Were you the driver of the vehicle?*

YES
NO

Were you the passenger in the vehicle?*

YES
NO

Were you a pedestrian?*

YES
NO

Were you a member of the policyholder's household?*

YES
NO

Do you or a relative with whom you reside own a vehicle?*

YES
NO

lf you were treated at a hospital were you an INPATIENT or OUTPATIENT?*

Inpatient
Outpatient
Neither

Date of admission:*

Name and address of Hospital:*

Were you treated by a doctor(s) or other people furnishing health services?*

YES
NO

Name and address of such doctor(s) or person(s)*

Will you have more health treatment?*

YES
NO

At the time of the accident, were you in the course of your employment?*

YES
NO

Did you lose time from work?*

If so, how much time?

lf so, what are your average weekly earnings?

Were you receiving unemployment benefits at the time of the accident?*

YES
NO

lf you lost time from work, date absence began

Have you returned to work?*

YES
NO

Date you returned

Number of days you work per week*

Number of hours per day*

List the name and address of your employer and other employers for one year prior to the date of accident giving occupation and date of employment:*

As a result of your injury, have you had any other expenses?*

YES
NO

lf so, explain

Due to this accident, have you received or are you eligible for payments under any of the following

New York State Disability*

YES
NO

Workers' Compensation*

YES
NO

AUTOMOBILE INSURANCE INFORMATION

YOUR AUTO INSURANCE COMPANY:*

POLICY #*

CLAIM #*

NAME OF CLAIMS REPRESENTATIVE (if known)

OTHER VEHICLE INFORMATION (if known)

INSURANCE COMPANY

PLATE #

CLAIM #

WHAT IS THE NAME OF YOUR PRIVATE HEALTH INSURANCE COMPANY?*

ARE YOU RECEIVING PUBLIC ASSISTANCE AND/OR MEDICAID BENEFITS?

YES
NO

ANY PRIOR ACCIDENTS? INJURIES? IF SO, PLEASE BRIEFLY EXPLAIN

THE ABOVE STATED INFORMATION IS ALL TRUE TO THE BEST OF MY KNOWLEDGE

(PLEASE SIGN AND DATE BELOW)

Signature*

Date*

Note to Clients:

Clients deserve to be kept informed and updated on the status of their cases. We will make a continued effort to assure that you understand what is happening with your case. please let us know whether you prefer periodic written updates, telephone updates, e-mail updates or scheduled office appointment updates. Please check your choice(s) below.

SELECT UPDATE PREFERENCE*

Select All
WRITTEN UPDATES
TELEPHONE UPDATES
SCHEDULED IN-OFFICE APPOINTMENTS
E-MAIL UPDATES

Email