1. PERSONAL INFORMATION ABOUT THE INJURED PERSON 

Today's Date

 Full Name

Email Address

Home Phone Number

Home Address

Business Phone

Employer

Birthdate

Place of Birth

Social Security Number

Marital Status
Married Divorced Single

Year married?

Name of Spouse

Name of Person Filling Out This Form

2. TYPE OF CASE

Type of Case?
Rear End Intersection Other

3. INFORMATION ABOUT THE PEOPLE WHO CAUSED THE DAMAGE.
We need to know about each potential defendant.  Fill out as many blanks as necessary..

How many people caused the damage?
One Two Three Four

Name and Address of Defendant 1 and Name and Address of Defendant 1's Insurance Company

Name and Address of Defendant 2 and Name and Address of Defendant 2's Insurance Company

Name and Address of Defendant 3 and Name and Address of Defendant 3's Insurance Company

Name and Address of Defendant 4 and Name and Address of Defendant 4's Insurance Company

 

4.  IMPORTANT DATES AND PLACES

When were you injured (Month,  Day,  Year)

Where did the injury take place 

 

5.  TAKE AS MANY WORDS AS NECESSARY TO TELL US WHAT HAPPENED

7. INVESTIGATED BY POLICE?
Yes No

If investigated by police, name of police department

 

8. INJURIES.

Describe in detail the injuries you received in the accident.  Often injuries change over time.  Try to give us enough information about what has happened to you since the accident so that we could explain it to an insurance adjuster.  

Tell us how you are doing right now.

 

9. NAMES, ADDRESSES, AND TELEPHONE NUMBERS  OF ALL AMBULANCE COMPANIES,  DOCTORS,  HOSPITALS,  PHYSICAL THERAPISTS,  AND ANY OTHER HEALTH CARE PROVIDERS. 

Name, Address,  and Telephone Number of Healthcare Provider 1

Name, Address,  and Telephone Number of Healthcare Provider 2

Name, Address,  and Telephone Number of Healthcare Provider 3

Name, Address,  and Telephone Number of Healthcare Provider 4

Name, Address,  and Telephone Number of Healthcare Provider 5

Name, Address,  and Telephone Number of Healthcare Provider 6

Name, Address,  and Telephone Number of Healthcare Provider 7

Name, Address,  and Telephone Number of Healthcare Provider 8

Name, Address,  and Telephone Number of Healthcare Provider 9

Name, Address,  and Telephone Number of Healthcare Provider 10

Name, Address,  and Telephone Number of Healthcare Provider 11

Name, Address,  and Telephone Number of Healthcare Provider 12

10. YOUR INSURANCE

Have you filed a claim with your insurance company? Yes No

Name, Address,  Telephone Number, and Claim Number for your Auto Insurance (PIP).

11. FILING A REPORT WITH THE STATE

Have you filed a claim with the State of Oregon? Yes No

12.  WAGE LOSS

Have you lost any wages?
  Yes No

Explain your wage loss to me so that I could explain it to an adjuster.  How do you calculate your wage loss?.

Name, Address,  Tand elephone Number of the person at your employer who knows about your wage loss.

13. MISC.

Were you wearing a seat belt?
  Yes No

14. IF THERE IS ANY THING ELSE YOU WANT TO TELL US YOU CAN WRITE IT IN THE BOX BELOW.

 

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