Pre Accident Survey #1

Date of Accident/Injury:
MM slash DD slash YYYY
Client Name:*
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
Employer:
Address
Street Address: City: State: Zip:
Job Title
Date employment began:
MM slash DD slash YYYY
Salary Rate of Pay: $
Per:
How many hours per week:
Hourly: $
Per:
How many hours per week:
Benefits:
Amount you earned in the last full year before your injury: $
Did you receive a W-2:
- Yes
- No
Have you filed Income Tax Returns for the last 5 years:
- Yes
- No
Do you have copies:
- Yes
- No
1.2 Five Year Employment History
Most recent employer BEFORE your current one:
Employer:
Address
Street Address City State / Province / Region ZIP / Postal Code
Salary Rate of Pay: $
Per:
How many hours per week:
Hourly: $
Per:
How many hours per week:
Benefits:
1.3 Spouse’s Employment
Is your spouse presently employed:
- First Choice
- Second Choice
- Third Choice
2. HEALTH AND HOSPITALIZATION HISTORY
2.1 Past Hospitalizations Before Your Accident
Were you EVER AT ANYTIME received treatment at a hospital BEFORE this accident for any reason:
- Yes
- No
If yes, please complete the following:
Most recent hospital treatment BEFORE the accident:
Address
Street Address City State / Province / Region ZIP / Postal Code
Reason for Hospital treatment:
Length of Hospital treatment: (From)
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Next hospital treatment BEFORE the accident:
Address
Street Address City State / Province / Region ZIP / Postal Code
Reason for Hospital treatment:
Length of Hospital treatment: (From)
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
2.2 Past Illnesses
BEFORE this accident, did you have had ANY long-lasting, chronic or serious illnesses for which you sought medical treatment?
- Yes
- No
If yes, please complete the following:
Doctor:
City:
State
Nature of Illness:
Date
MM slash DD slash YYYY
Doctor:
City:
State
Nature of Illness:
Date
MM slash DD slash YYYY
Doctor:
City:
State
Nature of Illness:
Date
MM slash DD slash YYYY
2.3 Accidents, Broken Bones or Injuries Before This Accident
BEFORE this accident did you have any injuries or medical conditions of any kind which required medical attention?
- Yes
- No
If yes, please furnish the following information:
Doctor
City:
State:
Date
MM slash DD slash YYYY
Nature of Accident:
Injury:
Doctor
City:
State:
Date
MM slash DD slash YYYY
Nature of Accident:
Injury:
Doctor
City:
State:
Date
MM slash DD slash YYYY
Nature of Accident:
Injury:
2.4 Past Medical/Dental Information
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.
Primary Care Doctor:
Dates Seen:
through
Address
Street Address City State / Province / Region ZIP / Postal Code
Reason(s) for treatment:
Dentist:
Dates Seen:
through
Address
Street Address City State / Province / Region ZIP / Postal Code
Reason(s) for treatment:
Other Dr. or Health Care Provider
Dates Seen:
through
Address
Street Address City State / Province / Region ZIP / Postal Code
Reason(s) for treatment:
Did you use any drugs or medications regularly (more than one refill) BEFORE your accident:
- Yes
- No
If yes, please name each drug or medication and its purpose:
Drug:
Purposes:
Drug:
Purposes:
Drug:
Purposes:
Drug:
Purposes:
- Auto
Date
MM slash DD slash YYYY
Reason:
- Life
Date
MM slash DD slash YYYY
Reason:
- Health
Date
MM slash DD slash YYYY
Reason:
3. INSURANCE INFORMATION
3.1 Medical Insurance
Do you have any medical insurance policies, including any medical insurance through your employment, or a private medical policy:
- Yes
- No
If so, please furnish the following information:
Name of Insurance Company:
Address
Street Address City State / Province / Region ZIP / Postal Code
Insurance Agent, if any:
Policy Number:
Who pays for this coverage
Have you made any claim for payment of your accident-related medical bills from:
Your medical insurance:
- Yes
- No
Other insurance company:
- Yes
- No
Medicaid/Medicare:
- Yes
- No
Other sources:
- Yes
- No
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:
Name of entity paying bills:
Name of entity paying bills:
Name of entity paying bills:
Do you have any insurance of any kind which would provide disability payments
- Yes
- No
If yes, please furnish the following information:
Name of Insurance Company:
Address
Street Address City State / Province / Region ZIP / Postal Code
Insurance Agent:
Phone No: