Auto Lead Intake

INTAKE SPECIALIST*
CASE TYPE*
CALLER NAME
RELATION TO CLIENT
CLIENT NAME:
First Middle Last
CLIENT ADDRESS:
Street Address City ZIP / Postal Code
State
Date of birth:
MM slash DD slash YYYY
Gender:
HOME TELEPHONE#:
MOBILE #:
ALTERNATIVE #:
MOBILE PROVIDER:
EMAIL:
INCIDENT DATE:
MM slash DD slash YYYY
INCIDENT TIME:

: Hours

Minutes

AM/PM
ACCIDENT LOCATION DESCRIPTION:
ACCIDENT LOCATION
Street Address City Country
State
NUMBER OF VEHICLES INVOLVED IN THE ACCIDENT:
- NONE
- ONE
- TWO
- THREE
- FOUR OR MORE
WAS CLIENT A DRIVER/PASS/PEDESTRIAN:
ACCIDENT COMPANION (S):
DESCRIPTION OF ACCIDENT:
POLICE AGENCY:
DO YOU HAVE A COPY OF THE ACCIDENT REPORT?
- YES
- NO
CRASH REPORT #:
WHO WAS TICKETED FOR THE ACCIDENT?
- ME
- THE DRIVER OF THE CAR I WAS IN
- NO TICKETS ISSUED
- I DONT KNOW
- OTHER DRIVER
CRASHED VEHICLE DESCRIPTION:
Year:
Make:
Model
CRASHED VEHICLE OWNER:
First:
Middle:
Last:
CRASHED VEHICLE INSURANCE:
Company:
Policy:
CLIENTS VEHICLE INSURANCE:
Company:
Policy:
UM:
CRASHED VEHICLE DAMAGE:
- NO DAMAGE
- MINOR SCRATCHES OR BUMPS
- MAJOR STRUCTURAL DAMAGE
- THE VEHICLE IS TOTALED/ WILL LIKELY NOT BE REPAIRED
- OTHERS
AFV VEHICLE DAMAGE:
- NO DAMAGE
- MINOR SCRATCHES OR BUMPS
- MAJOR STRUCTURAL DAMAGE
- THE VEHICLE IS TOTALED/ WILL LIKELY NOT BE REPAIRED
- OTHERS
AFV VEHICLE INSURANCE:
Company:
Policy:
PD PICS TAKEN:
CURRENT LOCATION OF CRASHED VEHICLE:
CLIENT LEFT SCENE BY:
INJURIES:
- LOWER BACK PAIN
- UPPER BACK PAIN
- SHOULDER PAIN
- NECK PAIN
- HEADACHES
- NAUSEA
- DIFFICULTY SLEEPING
- CUTS AND BRUISES
- BROKEN BONES
- LOSS OF FEELING IN PART OF BODY
- DIFFICULTY BREATHING
- IMPAIRED VISION
- MEMORY LOSS
- OTHER
DESCRIPTION OF ACCIDENT INJURIES
STATUS OF MEDICAL TREATMENT:
- NONE
ER VISIT:
MEDICAL DOCTOR:
SURGEON:
CHIROPRACTOR:
ACUPUNCTURIST:
PHYSICAL THERAPIST:
OTHERS
MEDICAL TREATMENT FACILITY LOCATION:
MISSED TIME FROM WORK BECAUSE OF THE INJURY?
- NO
- YES
NUMBER OF MISSED WORK DAYS:
DESCRIPTION OF ANY PRIOR INJURIES:
REFERRAL SOURCE:
ADDITIONAL INFORMATION: