Motor Vehicle Collision Questionnaire Step 1 of 5 20% Name:First NameMiddle NameLast NameEmail Date of Collision: Date Format: MM slash DD slash YYYY Time of Collision: : HH MM 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?YesNoNumber of people in your vehicle:Were you wearing a seatbelt?YesNoType of Collision:BroadsideFrontal ImpactHit a Stationary ObjectRear ImpactOtherIn your own words, describe the accident: Were you knocked unconscious?YesNoHow long were you unconscious?Approximate speed of your vehicle:Approximate speed of other vehicle:Please describe the road conditions:DryIcySnowyWetHow 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?YesNoWas 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?YesNoName of Attorney: Since this collision, are your symptoms?ImprovingGetting WorseStaying the SameUnsurePlease 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.?YesNoActivities that are affected: Auto Insurance InformationDid you report this accident to your insurance company?YesNoName 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please Enter the Above Code and Click "Submit" to Complete this Form. This iframe contains the logic required to handle Ajax powered Gravity Forms.