Auto Accident Injury Information Form printable pdf download

Auto Accident Injury Information

Name:____________________________

Today’s Date:_____________

Date of Accident:___/___/_____

Name of Attorney (If Represented):_____________________________

Please describe how the accident occurred (give details):

____________________________________________________________________________________________________

What was your position in the vehicle?

( ) The driver

( ) The rear passenger ( ) The front passenger

( ) A pedestrian

( ) Other: ____________

What type of vehicle were you driving?

( ) Compact car ( ) Full size car

( ) Full size truck

( ) Full size van

( ) Mid size car

( ) Compact truck ( ) Mini van ( ) Compact

( ) sport utility

vehicle ( ) Full size sport utility vehicle ( ) Motorhome

( ) Motorcycle ( ) Bicycle

( ) Other: ____________

What speed were you traveling at the time of the accident?

( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down at an intersection ( ) Moving slowly ( ) Traveling at approximately ___ mph

( ) Merging into traffic ( ) Traveling faster than 65 mph ( ) Other: _____________________

Who hit whom?

( ) Was struck by another vehicle

( ) Struck a stationary object ( ) Struck another vehicle

( ) Other: _____________

What was your vehicle's point of impact?

( ) On the front ( ) On the left front ( ) On the rear ( ) On the left rear ( ) On the right front ( ) On the middle front ( ) On the right rear ( ) On the middle rear

( ) On the right side ( ) On the rear right side ( ) On the left side ( ) On the front right side ( ) On the middle right side ( ) On the front left side

( ) On the rear left side ( ) On the middle left side ( ) Other: __________

What speed was the other vehicle traveling?

( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down for an intersection ( ) Moving slowly ( ) Merging into traffic ( ) Traveling faster than 65 mph

( ) Traveling at approximately ___ mph ( ) Other: ______________________

What was the other vehicle's point of impact?

( ) On the front ( ) On the left front ( ) On the rear ( ) On the right front

( ) On the middle front

( ) On the right rear ( ) On the left rear ( ) On the right

side ( ) On the rear right side ( ) On the middle rear

( ) On the front right side ( ) On the middle right side ( ) On the left side ( ) On the rear left side

( ) On the front left side ( ) On the middle left side ( ) Other: ______________

Were you wearing seat restraints?

( ) Was wearing a full lap and shoulder restraint

( ) Was wearing a shoulder restraint ( ) Was wearing a lap restraint ( ) Was not wearing any seat restraints

( ) Other: ______________________

What position were your vehicle head rests in?

( ) Did have a head rest which was adjusted in the lowest position ( ) Did have a head rest which was adjusted in the middle position

( ) Did have a head rest which was adjusted in the highest position ( ) Was not equipped with a head rest

( ) Other: _____________________

Did your air bag deploy?

( ) Air bags were deployed

( ) Air bags were not deployed

( ) Other:____________

Were you prepared for the impact?

( ) Was completely surprised by the accident ( ) Saw the collision coming and braced appropriately ( ) Saw the collision coming

( ) Other: _____________________

What position was your body in just prior to impact?

( ) A straight position ( ) A position rotated to the left ( ) A tilted forward position ( ) A position rotated to the right ( ) A position that cannot be remembered

( ) Other: _________________

Auto Accident Injury Information Form

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