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Incident Questionnaire

Page 2 of 2

First Name

Middle Name

Last Name

Accident Information

Local Authorities Called:
Police/Highway Patrol: YesNo Ambulance Called: YesNo Fire Dept: YesNo

Police Report Taken:
Yes No:

Name of Authority taking Report

Other Information

FACTS: In your own words, describe how the incident occurred;

What injuries resulted from the incident, who was injured, and how have the injuries progressed?

What medical treatment has taken place?

Medical Expenses to Date:

Time Loss from Work to Date:

Property Damage:

Ambulance, Transportation Costs, Car Rental, etc:

Any Other Losses:

Submit this form only after completion of page 1 Reset clears entire page 2:

Disclaimer: The material contained in this web site is not intended as legal advice, and you should not rely upon it being applicable to any specific case you may have. We are not giving advice and we do not and cannot guarantee the outcome of any specific case. We are not yet your lawyers as interaction between us either with e-mail on this page or our personal injury questionnaire does not constitute the creation of an attorney/client relationship until such relationship is mutually agreed upon in writing and executed by all parties. The information supplied on this web site is general in nature and should not be relied upon to make legal decisions. This web site is an advertisement for legal services. All information contained in this web site pertains to the law in the State of California only.