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When you were injured, were you the driver or the passenger of the vehicle, on a motorcycle, a pedestrian, or did you slip and fall?

In order to better understand your case we would like to gather some more information. Please complete the form below and Larson Law will review the information and contact you within 72 hours. Please note, This is this is a CONFIDENTIAL and ENCRYPTED questionnaire for the use of this office only in preparing your claim for personal injuries. Please answer every question fully, honestly, and accurately because, as your attorneys, the more we know about you and your case, the better we will be able to represent you. There are 13 sections, and each of the questions are important even though they may not appear to have anything to do with your case.

Was there any prior damage to your vehicle? If so, where?

Were you transported by ambulance? If so, which ambulance service?

Medical Providers

Please provide the following information for each and every medical provider who has treated you since the accident. This information is very important. Failure to provide information may cause medical expenses to be incorrect for which you may be liable.

Was the vehicle drivable after the accident?

Defendant's auto insurance company:

Name, address, phone number, and fax number of the medical provider:

Which police department sent officers, and what was the report number?

Full name:

Your Vehicle Information

List the names, addresses, phone numbers, relationships, and ages for any passengers in your car:

Have you obtained an estimate of the damage to your vehicle? If so, please upload copies:

Other Insurance Information

Accident Information

Please provide the adjuster's name and phone number and the claim number:

Year, make, and model:

Was your vehicle drivable after the accident? Where is your vehicle now?

First, middle, and last Name: *

Name, address, phone number, and fax number of the medical provider:

Address (street, city, state, and zip code):

Any other important information regarding the defendant or his/her actions?

I have read and completed the above information and state that it is true and correct to the best of my knowledge:

Drivers license number:

Social Security Number:

Name, address, phone number, and fax number of the medical provider:

Defendant's Auto Insurance Information

(Defendant is the driver who caused the accident)

Please upload a copy of your health insurance identification card:

Have you told any police officer, investigator, insurance adjuster, or any other person about the accident? If so, what did you say and to whom?

Please provide the posted speed limit and describe the weather and road conditions:

Name, address, phone number, and fax number of the medical provider:

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Date, time (AM/PM) of the accident:

Date and time *

Besides auto coverage, please list any other health, medical, and/or dental insurance in force at the time of the accident:

If yes, please provide name and phone number of the employer you were working for at the time of the accident, your job title and type of work, your gross pay (hourly, weekly, or monthly), and the number of days you missed work because of the injuries from this accident:

Please provide the adjuster's name and phone number and the claim number:

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Name, address, phone number, and fax number of the medical provider:

Do you have photos of the defendant's damaged vehicle? If so, please upload copies:

Name, address, and phone number of the driver who caused the accident:

Email address:

Year, make, and model:

List in full detail all injuries you received as a result of this accident (include emotional, mental, and physical injuries):

Please provide any photos of the accident scene:

Has the insurance company been notified of the accident and told that you were injured?

What insurance company insured the car you were in?

Your Auto Insurance Information

Did you go to a hospital emergency room? If so, which hospital, and was it the same day?

Do you have Medicaid or Medicare? If so, please provide the ID number:

Statements Made

Please draw and upload a diagram of the accident (include street labels and directions of travel):

Name, policy number, and claim number of the insured:

Describe how the accident happened:

Where did the accident occur?

Have you ever been charged with a crime? If so, please indicate the nature of the charge, the approximate date, the court where the charge was handled, and the ultimate resolution of the charge:

Defendant's Vehicle Information

List in full detail all symptoms that you experienced in the first 30 days after the accident (include emotional, mental, and physical symptoms):

Name, address, phone number, and fax number of the medical provider:

List in full detail all symptoms that you continue to experience as a result of this accident:

Date of birth (month, day, year):

Injuries

Have you received forms from your insurance company to fill out for benefits? If so, please upload a copy:

Conclusion

Have you missed any time from work as a result of your injury?

Police Record

Marital status (married, single, divorced, separated, or widowed), and name of spouse if married:

Phone numbers (home, work, and cell): *

Personal Information

Wage Loss

List specific ways this accident has affected your life. Is there anything you are no longer able to do?

Is there any other information which you feel may be helpful to your case? Please express any feelings or frustrations this accident has caused in your life:

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Medical Providers

Your Vehicle Information

Other Insurance Information

Accident Information

I have read and completed the above information and state that it is true and correct to the best of my knowledge:

Defendant's Auto Insurance Information

​(Defendant is the driver who caused the accident)

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Your Auto Insurance Information

Statements Made

Defendant's Vehicle Information

Injuries

Conclusion

Police Record

Personal Information

Wage Loss

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(Defendant is the driver who caused the accident)