Accident Information

In your own words, please briefly describe the accident/injury:

Please detail the damages to your vehicle if your case concerns an automobile accident:

Were pictures taken of the damage to your vehicle? Yes No

If pictures were taken, please make them available to our office.

Loss of Income

Are you claiming a loss of income as a result of this accident/injury? Yes No

If yes, please provide information as to the following:

Dates missed from work:

Wage per hour: or Salary per month:

With regard to missed hours, did you:

Receive a reduction in pay for missed time; Use vacation time;
Use sick time; or Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

Medical Information

Please list all medical providers you have seen as a result of this accident/injury below:

Medical Care Provider	Address

Have you had surgery as a result of this injury/accident? Yes No

If so, at what facility?
Date of Surgery: / /

Please list the medical care providers you have seen previous to this accident/injury within the past ten (10) years below:

Medical Care Provider	Address

What were your injuries from the accident?

What injuries still effect you (continuing symptoms)?

Changes in Lifestyle

Please describe in detail the activities you performed prior to the subject accident that you are no longer able to perform:

Please describe in detail how your injuries have changed your life:

With regard to missed hours, did you:

Receive a reduction in pay for missed time; Use vacation time;
Use sick time; or Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

Insurance Information

YOUR automobile insurance information:		OTHER PARTY insurance information:
Company:		Company:
Address:		Address:
City, State Zip:		City, State Zip:
Telephone Number:		Telephone Number:
Agent:		Agent:
Agent Address:		Agent Address:
Agent Telephone Number:		Agent Telephone Number:

Have any expenses been paid by either insurance company? If so, explain:

Do you have personal medical insurance: Yes No

If so, please provide: Name of insurance company:

Address:

Policy #:

Have any expenses been paid by your personal medical insurance company? If so, explain:

Have you personally paid any expenses? If so, explain: