Protecting Accident Victims Since 1983

Pre Accident Survey #1

Pre Accident Survey #1



IMPORTANT:
We must have the information in this survey to complete your claim!
Please complete this survey and return it to us within the next 10 days.


PRE-ACCIDENT SURVEY #1




1. EMPLOYMENT HISTORY


1.1 Employment at the Time of Your Accident
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Address





Job Title

Date employment began:

Salary Rate of Pay: $

Per:

How many hours per week:

Hourly: $

Per:

How many hours per week:




YesNo


YesNo


YesNo

1.2 Five Year Employment History
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Address












1.3 Spouse’s Employment

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First ChoiceSecond ChoiceThird Choice


2. HEALTH AND HOSPITALIZATION HISTORY

2.1 Past Hospitalizations Before Your Accident

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YesNo

If yes, please complete the following:


Address







2.2 Past Illnesses

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YesNo

If yes, please complete the following:







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2.3 Accidents, Broken Bones or Injuries Before This Accident

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YesNo
If yes, please complete the following:







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2.4 Past Medical/Dental Information

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In the FIVE YEARS BEFORE YOUR ACCIDENT, who has been your regular family doctor and dentist that you have consulted when you needed medical attention? If more than one doctor, dentist, osteopath, chiropractor, or other physician has been used by you, please indicate below.




Address






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Address






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Address






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YesNo

If yes, please name each drug or medication and its purpose:









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Auto



Life



Health




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3. INSURANCE INFORMATION

3.1 Medical Insurance

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YesNo
If so, please furnish the following information:


Address








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Have you made any claim for payment of your accident-related medical bills from:

Your medical insurance:
YesNo

Other insurance company:
YesNo

Medicaid/Medicare:
YesNo

Other sources:
YesNo

If any of your accident related medical bills been paid by a health insurance company, Medicaid, Medicare or any person other than yourself, please furnish the following information:





YesNo

If yes, please furnish the following information:

Address






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