Elixia Motor Vehicle Accident Injury History Form
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2MOTOR VEHICLE ACCIDENT INJURY HISTORY FORM
Name: ___________________________________
Date: ______________
HISTORY
Date of Injury: ______________
Time of Day: _____
Weather Conditions: ______
How did the accident happen?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Y / N Were there witnesses?
If yes, provide their names: _____________
Y / N Was a police report filed?
Y / N Did you contact your insurance company on this claim?
Y / N Have they sent you a PIP form?
If yes, have you returned it? Y / N
Y / N Have you been contacted by a claim representative/insurance adjuster?
Y / N Do you have an attorney who has advised you on this case?
If yes, please provide name, address: __________________________________
Name of your insurance company___________________________________________
Insurance Adjuster’s: Name_______________________ Phone #__________________
Your Claim # _____________________ PIP Max______________________________
FOR MOTOR VEHICLE ACCIDENTS: (please circle or fill in blanks)
Were you the:
Driver
Passenger
Pedestrian
Your location in car:
L Front
R Front
R Rear
L Rear
Cross streets/location of accident: ___________________________________________
You were headed:
North
South
East
West
The other vehicle was going: North
South
East
West
The impact was from:
Front
Rear
Right
Left
At impact you were looking: Right
Left
Straight ahead
Unknown
If driving, were hands on the wheel?
Y
N
N/A
If driving, was foot on brake?
Y
N
N/A
Did head hit headrest?
Y
N
N/A
Were you braced for impact?
Y
N
N/A
Were you wearing seatbelt? Lap belt only
Lap/Shoulder Combo
No
Were you doing something at impact?
Y
N
Describe: _______________
Did you strike anything in the car:
No
If yes, specify: _______________________
What part(s) if body struck above: ___________________________________________
Did you lose consciousness?
Y
N
If yes, how long? _________
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