CONFIDENTIAL CLIENT INFORMATION FORM

Who Referred You To Our Office?

Personal Information

Full Name: *

Phone Number:

Date of Accident: *

Social Security Number:

Address: *

Other Parties Involved in Accident:

Your Car Insurance and Medical Insurance

** Please Provide Us With A Copy Of Proof Of Car Insurance ** Upload at bottom if available

1.

Name of your automobile insurance company and policy number and make, model, year of car:

2.

Does your policy provide medical payments to you?
YesNo

Amount of Coverage:

3.

Does your policy provide Uninsured or Underinsured coverage? If so, what is the
amount of coverage:

4.

Do you have insurance covering damage to your car? If so, what is the deductible amount?

5.

Do you have THIRD PARTY health insurance? (usually provided to you or your spouse OR
through an employer)? This Includes Sooner Care and/or Medicare/Medicaid

Who is the insured?

DOB:

We Will Need To Make a Copy Of Your Insurance Card - Upload at bottom if available

Accident Information

1. Who was driving the car?

2. Within 48 hours prior to the accident, had you (or driver) consumed any alcohol, drug or medication? Prescribed or otherwise?

3. Was there anything else either prior or at the time of the accident, that you think might have affected your (or the driver) reflexes, concentration, physical abilities and/or mental capacities?

4. Was the driver of the other vehicle impaired in any way?

5. Was the car towed?
YesNo

If so, where?:

6. Did the air bags deploy?
YesNo

7. Did the police arrive on the scene (please indicate which police department)?:

8. Is there a police report?
YesNo

9. Was a citation issued? If yes, to whom?:

10. Please list the city/town, the intersection, and the time of day the accident occurred:

11. Have you settled your property damage?
YesNo

12. Please list the following information abour your property damage:

13. Have you been provided a rental car?
YesNo

Have you ever received a traffic citation or been convicted of a crime?
YesNo

If yes, please list the date, location, the charge, and the result:

Has your license (or the driver's license) ever been suspended?
YesNo

If yes, please explain:

Have you ever been involved in any claim or lawsuit for personal injury?
YesNo

If yes, please list the date, attorney, claim, and settlement result:

If available, upload your proof of car insurance (png, jpg, jpeg, pdf files only):

If available, upload your third party insurance card (png, jpg, jpeg, pdf files only):