| Today's
date: _________________________________
Plaintiff name: _________________________________
Address: _____________________________________
____________________________________________
____________________________________________
Phone Number: _______________________________
Email: ________________________________________
d/o/b: ________________________________________
Soc.. security: __________________________________
Spouse _______________________________________
2a. Date of Accident: _____________________________
town, county, state: _______________________________
day of week _____________________________________
time: _________________________________
weather _________________________________
Road conditions _______________________________________________________________________
Description of Accident: _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2b. Operator of Plaintiff's car: _____________________________________________________________
Owner of Plaintiff's car: __________________________________________________________________
2c Other occupant's of Plaintiff's car. ________________________________________________________
2d Street Plaintiff was traveling on: __________________________________________________________
Direction of travel (ex- North, south, etc.): ____________________________________________________
Nearest approaching road: ________________________________________________________________
2e Street Defendant was traveling on: ________________________________________________________
Defendant Direction of travel (ex- North, south, etc.): ____________________________________________
Nearest approaching road: ________________________________________________________________
2f Traffic lights or stop signs in area: _________________________________________________________
3. INJURIES- NATURE, EXTENT, DURATION
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. PERMANENT INJURIES AND PRESENT COMPLAINTS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. HOSPITALS- ADDRESS, DATE OF ADMISSION DISCHARGE
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6- X-RAYS, TAKEN BY: _________________________________
ADDRESS: ____________________________________________________________________________
DIAGNOSTIC TESTS: ___________________________________________________________________
X-ray, MRI DATE _________________________________
RESULTS _________________________________
7 DOCTOR-NAME _________________________________
ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
7B. MEDICAL PROVIDER-NAME __________________________
ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
7C MEDICAL PROVIDER-NAME ADDRESS PHONE DATES OF TREATMENT: _________________________________
DATE OF REPORTS: _________________________________
8. STILL BEING TREATED? MEDICAL PROVIDER-NAME NATURE OF TREATMENT
AND NATURE OF TREATMENT
9. AGGRAVATION OF PRIOR INJURIES BY ACCIDENT, PRIOR DOCTOR
10. Employer Name: __________________________________ Address:
____________________________________________
Job/Position Gross/week Net/week Time Lost Total Wages Lost: _____________________________________________________
11. IF RETURN TO WORK: _________________________________ Current
Employer Name: _________________________________
Address: _________________________________ Job: _________________________________
______________ Gross/week Net/week
12- OTHER LOSS OF INCOME, EARNINGS
13. Medical bills, Doctor Amount unpaid Paid hospital bills, medicine,
etc. Total medicals (As of ________): _________________________________
14. OTHER OUT OF POCKET EXPENSES and OTHER LOSSES
15. Relevant Documents: __________________________________________________________________
Identify all documents that may relate to this action, and attach
copies of each such document, such as police report, hospital bills,
etc.
Police Report: _____________________________________________________________________________
Declaration Sheet: __________________________________________________________________________
Hospital Bills: ______________________________________________________________________________
Hospital Records: ___________________________________________________________________________
Medical Bills and Records: ____________________________________________________________________
Photographs of Accident Site: __________________________________________________________________
Photographs of Damage to Plaintiff's car: __________________________________________________________
Photographs of Damage to Defendant's car: ________________________________________________________
Photographs of Injuries, scars, cuts: _______________________________________________________________
Repair damage estimate: _______________________________________________________________________
Other: _____________________________________________________________________________________
16a defendant name: _________________________________ _________________________________
address: _______________________________
_________________________________ Owner of Def car: _________________________________
address: _________________________________
Type of car: _________________________________ ___________________________
make, year Other occupants of def car
16b Eye witness name: _________________________________ address
& phone: _________________________________
17 Names and addresses of People with Relevant Knowledge
Officers of Investigating Police Department: _________________________________
18. Photographs: _________________________________ _________________________________
If any photographs, videotapes, audio tapes or other forms of electronic
recordings, sketches, reproductions, charts or maps were made with
respect to anything that is relevant to the subject matter of the
complaint, describe: _________________________________ _________________________________
(a) the number of each; (b) what each shows or contains; (c) the
date taken or made; (d) the names and addresses of the persons who
made them; (e) in whose possession they are at present; and (f)
if in your possession, attach a copy, or if not subject to convenient
copying, state the location where inspection and copying may take
place. ___________
19. If you claim that the defendant made any admissions as to the
subject matter of this lawsuit, state: _________________________________
_________________________________ (a) the date made; (b) the name
of the person by whom made; (c) the name and address of the person
to whom made; (d) where made; (e) the name and address of each person
present at the time the admission was made; (f) the contents of
the admission; and (g) if in writing, attach a copy.
20. If you or your representative and the defendant have had any
oral communication concerning the subject matter of this lawsuit,
state: _________________________________ _________________________________
(a) the date of the communication; (b) the name and address of each
participant; (c) the name and address of each person present at
the time of such communication; (d) where such communication took
place; and (e) a summary of what was said by each party participating
in the communication.
21. If you have obtained a statement from any person not a party
to this action, state: _________________________________ _________________________________
(a) the name and present address of the person who gave the statement;
(b) whether the statement was oral or in writing and if in writing,
attach a copy; (c) the date statement was obtained; (d) if such
statement was oral, whether a recording was made, and if so, the
nature of the recording and the name and present address of the
person who has custody of it; (e) if the statement was written,
whether it was signed by the person making it; (f) the name and
address of the person who obtained the statement; and (g) if the
statement was oral, a detailed summary of its contents. _____________________________
22: _________________________________ ___________________________
Violation by Defendant of Motor Vehicle law (i.e. Careless driving
or other statute
23. Expert witnesses: _________________________________ 24. Have
you every been indicted and convicted of a crime? ______ (This question
required by Rules of Court)
25a Plaintiff car ins company: _________________________________
THRESHOLD address: _________________________________ phone: _________________________________
policy # claim # year, make, model collision coverage Who Notified?
UM/ UIM coverage
25b Named Insured: _________________________________ _________________________________
_____________________________________
25c Copy of Dec Sheet: _________________________________
25d. Plaintiff's private major- medical ex- Blue Cross address:
_________________________________ phone: _________________________________
Policy number
26a: Distance between Plaintiff and point of impact when first
observed other vehicle and Plaintiff's speed: _________________________________
26b: distance between Plaintiff and the Defendant's vehicle when
first observed other vehicle: _________________________________
___________________________________________________________
26c: Where Plaintiff's vehicle came to rest and where Defendant's
vehicle came to rest: _____________________________ ___________________________________________________________
27: Part of Plaintiff's car hit by Defendant's car: _________________________________
________________________________________________________
Damage to Plaintiff's car: _________________________________ _________________________________
_______________________________________
Property damage estimate: _________________ ___________________________________________________________
28: Where Plaintiff was coming from and where Plaintiff was going
to: _________________________________ ___________________________________________________________
29. Parts of body hitting car: _________________________________
_________________________________ _____________________
30. Unconsciousness? _____________________
31. Skid marks by any car: _________________________________ _________________________________
_____________________
32. Defendant's Ins carrier 33. address: _________________________________
phone: _________________________________ 34. adjuster: _________________________________
35. Policy limits: _________________________________ claim #: _________________________________
36. When did you apply your brakes?: ___________________________
_________________________________ _____________________
37. How fast were you going?: _________________________________
_________________________________ _____________________
38. How fast was the Defendant going?: _________________________________
_________________________________ _____________________
39. Describe the position of each car at the point of impact, giving
distance from curb, lines, streets or other landmarks?: _________________________________
_________________________________ _____________________
40. Alcoholic beverages or medication within 12 hours before accident?
_______
41. Prior accidents involving injury in which you received an insurance
settlement or suit was started? (Including worker's compensation)?
Prior car accidents with only property damage? _____________________
42. Negligent actions by Defendant: _________________________________
_________________________________
43. What else did you tell police? _____________________
44. Set forth the names of insurance agents and other individuals
you discussed the case with an what did you say? _____________________
45. Please prepare a Diagram of the accident site _____________________
46. Are you receiving Medicare/ Medicaid? ___________ Are you receiving
SSI? ___________
Is there anything else important? ___________________________
___________________________________________________________ ___________________________________________________________
Documents to be supplied to attorney & in his possession: Police
Report: _________________________________ Declaration Sheet: _________________________________
Medical/ Hospital Bills and Records: _________________________________
Photographs of Accident Site: _________________________________
Photographs of Damage to Plaintiff's car: ___________________________
Photographs of Damage to Defendant's car: _________________________________
Photographs of Injuries, scars, cuts: _________________________________
Repair damage estimate: _________________________________
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