Pre Accident Survey #2

Date of Injury
MM slash DD slash YYYY
Client:
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 #2
1. MILITARY HISTORY
1.1 Military Background
Have you ever been in the military service:
- Yes
- No
If yes, dates:
To
Type of discharge received:
- Honorable
- Dishonorable
- Others
Do you have a Veterans Administration Number:
- Yes
- No
If yes, number:
Have you ever been rejected for military service because of physical or other reasons:
- Yes
- No
If yes, please explain:
2. EDUCATIONAL BACKGROUND
2.1 Schools / Training
High School
City:
State
Years Attended: (From)
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Graduated
- Yes
- No
College-University:
City:
State
Years Attended: (From)
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Graduated
- Yes
- No
Technical Training
City:
State
Years Attended: (From)
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Graduated
- Yes
- No
3. LITIGATION HISTORY
3.1 Police Record
Have you ever been arrested?
- Yes
- No
If yes, please give the following:
Date
MM slash DD slash YYYY
Country:
State:
Criminal Charge:
Have you ever been convicted?
- Yes
- No
If so of what crime?
Is there now or has there ever been any restriction on your driver's license
- Yes
- No
If yes, please give the details
Date of Suspension/Revocation:
MM slash DD slash YYYY
Reason:
Has your driver's license ever been suspended or revoked?
- Yes
- No
If yes, please give the details
Date of Suspension/Revocation: Date:
MM slash DD slash YYYY
Reason:
Have you ever received any traffic tickets:
- Yes
- No
If yes, please furnish the following information:
Nature of Traffic Ticket:
Date
MM slash DD slash YYYY
What was done about it:
Nature of Traffic Ticket:
Date
MM slash DD slash YYYY
What was done about it:
Nature of Traffic Ticket:
Date
MM slash DD slash YYYY
What was done about it:
4. CLAIMS AND COURT CASES
4.1 Claims & Court Cases
Have you ever made a claim for a work-related injury at any time:
- Yes
- No
If yes, complete following:
Date
MM slash DD slash YYYY
Injury(s)
Employer
Address
Street Address City State / Province / Region ZIP / Postal Code
Settlement received or outcome:
Have you ever filed a claim for Social Security Disability benefits:
- Yes
- No
If yes, complete following:
Date
MM slash DD slash YYYY
Claim Number:
Injury of medical condition you claimed was disabling:
Outcome:
Have you ever made a claim as a result of an automobile accident:
- Yes
- No
If yes, complete following:
Date
MM slash DD slash YYYY
City:
State:
Description of accident:
Injuries you received:
Amount received or outcome of claim:
Have you ever received a veteran's pension or benefits:
- Yes
- No
If yes, complete following:
Date
MM slash DD slash YYYY
Claim Number, if any:
Reason:
Outcome of claim:
Have you made any claims at any time for benefits from any other source?
(Disability insurance, unemployment benefits, etc.)
- Yes
- No
If yes, complete following:
Benefits sought:
Date
MM slash DD slash YYYY
Result
Benefits sought:
Date
MM slash DD slash YYYY
Result
5. RELIGIOUS/FRATERNAL/SPECIAL AFFILIATIONS
5.1 Religious and Fraternal Information
Religious affiliation:
Name of your clergyman:
Please list any memberships in Church Organizations, Lodges, Fraternal Organizations, Other Memberships, Public Offices Held, etc. (Include past or present affiliations)
Organization:
Organization:
Organization:
Member of any Union:
- Yes
- No
If yes, please list:
Name
Local Number:
6. HOBBIES AND SPECIAL INTERESTS
6.1 Hobbies / Special Interests
Please list any Hobbies you have:
Please list any Special Interests you have: