Motor Vehicle Collision Questionnaire Step 1 of 5 20% Name First Last Email Date of Collision: MM slash DD slash YYYY Time of Collision: : AM PM AM/PM Location of Collision:Where you the:Select an OptionDriverFront Seat PassengerRear Seat Passenger LeftRear Seat Passenger MiddleRear Seat Passenger RightDid the airbags deploy? Yes No Number of people in your vehicle:Were you wearing a seatbelt? Yes No Type of Collision: Broadside Frontal Impact Hit a Stationary Object Rear Impact Other In your own words, describe the accident: Were you knocked unconscious? Yes No How long were you unconscious?Approximate speed of your vehicle:Approximate speed of other vehicle:Please describe the road conditions: Dry Icy Snowy Wet How did you feel immediately after the collision?How did you feel later the same day?How did you feel the next day? Were you taken to the hospital? Yes No Was it by:AmbulanceCarHelicopterOtherName of the Hospital:How long were you in the hospital?What did they say was wrong with you?What tests did they perform?What type of treatment(s) did you receive for your condition? Medication Physical Therapy Surgery Other Other doctors you have seen since the collision:Is there an attorney involved? Yes No Name of Attorney: Since this collision, are your symptoms? Improving Getting Worse Staying the Same Unsure Please check all that you are experiencing or have experienced since the collision: Anxiousness Arm Numbness/Tingling Arm Pain Depression Dizziness Fainting/Lightheadedness Fatigue Grating Noises in Neck Head Seems Heavy Headache(s) Irritability Lack of Energy Leg Numbness/Tingling Leg Pain Lower Back Pain Light Sensitivity Loss of Balance Loss of Memory Mid Back Pain Muscle Cramping Muscular Tension/Stiffness Neck Pain Neck Stiffness Pinched Nerve Ringing in Ears Shortness of Breath Shoulder Blade Pain Shoulder Pain Sleeping Problems Tight Chest Upper Back Pain Other None of the Above Are there any daily activities that you are unable to do because of this collision such as sleeping comfortably, driving or sitting for long periods, lifting, sexual activity, etc.? Yes No Activities that are affected: Auto Insurance InformationDid you report this accident to your insurance company? Yes No Name of Your Auto Insurance Company:Agent's Name:Policy Holder's Name:Policy #:Claim # for this Accident:Name of Claims Adjuster:Phone # of Insurance Company:Address Where to Send Claims: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneThis field is for validation purposes and should be left unchanged.
