Kasich Law Offices

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MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

This form is intended as an aid to be used by persons who have recently been involved in a motor vehicle accident.

These questions are offered as a public service to help you make notes of the events that happened. Take this information to your attorney of choice when you meet with him/her the first time.

Keep this information absolutely confidential

Your Name:__________________________________________

Your Driver's License Number:__________________________________________

Your Spouse's Name:__________________________________________

The number of Children you have:__________________________________________

City:__________________________________________

State:_____________________________ Zip Code: _________________________

Home Phone:______________________ Work Phone:______________________

Fax:__________________________ E-Mail:__________________________

Date of Birth:__________________________

Social Security:__________________________

Date of Injury:______________________ Time of Injury: ______________________

Exact location of Accident:____________________________________________________
_________________________________________________________________________

Type of Injury:____________________________________________________

Car Insurance Co:____________________________________________________

Policy #:____________________________________________________

Medical insurance: Yes___________ No ________________

Limits: $_______________

Employer:____________________________________________________

Address:____________________________________________________

City:____________________________________________________

State:__________________________ Zip Code: __________________________

Other Party Information

(1): Name:__________________________________________

D/Lic#:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip:__________________________

Home Phone:______________________ Work Phone:______________________

Registered Owner of Car:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip:__________________________

Make of Car:__________________________________________

Model:__________________________________________

Year:__________________________

License Plate:__________________________________________

Insurance Co:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip:__________________________

Policy #:__________________________________________

Claim#:__________________________________________

Adjuster/Agent:__________________________________________

Phone#:_________________________

Other Party Information (2):

Name:__________________________________________

D/Lic#:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip:__________________________

Home Phone:______________________ Work Phone:______________________

Registered Owner of Car:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip:__________________________

Make of Car:__________________________________________

Model:__________________________________________

Year:__________________________________

License Plate:__________________________________________

Insurance Co:__________________________________________

Address:__________________________________________

City:__________________________________________

State:__________________________ Zip: ____________________

Policy #:__________________________________________

Claim #:__________________________________________

Adjuster/Agent:__________________________________________

Phone#:________________________________

Property Dmge: $__________________________________________

Loss of Use: $__________________________________________

Cost of Repair:$__________________________________________

If you are injured, it may be important that you book an appointment with your lawyer as soon as possible so that you can discuss the concepts of lost wages, pain and suffering, and medical bills. In addition, I can NOT overemphasize the suggestion that you may want to IMMEDIATELY begin keeping a "pain diary," a journal in which you will keep track of your pain, discomfort, inconvenience, as well as medical travel expenses, medication schedules, etc..

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WARNING: All information contained herein is provided solely for the purpose of giving basic information only. It should not be construed as formal legal advice. The author disclaims any and all liability resulting from reliance upon such information. You should seek and consult with your own professional legal counsel before relying upon any of the information contained herein.