Motor Vehicle Accident Intake Form

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GOROSPE LAW GROUP

Motor Vehicle Accident Intake Form

Protecting personal information that we collect from you is a top priority at the Gorospe Law Group. Using 2048-bit encryption protects the information by scrambling it as it is sent from your computer or device to our website. It helps to keep your information secure and private.

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Emergency Contact

Emergency Contact Phone

Date of Accident

Location of Accident

Was Law Enforcement Called?

Yes

Which Law Enforcement Agency?

Do You Have a Collision Report Number?

Yes

Collision Report Number

Describe how the accident occurred.

Were you the driver or passenger?

Driver

Passenger

If you were the passenger what position in the vehicle?

Were you wearing a seatbelt at the time of the accident?

Yes

Did airbags deploy?

Yes

List any other occupants of the vehicle:

List any witnesses to the accident:

Describe any communication you had with anyone at the scene (witnesses, other driver, law enforcement, paramedics, etc.) :

Was the vehicle drivable from the scene?

Yes

Has your vehicle been repaired or considered a total loss?

Repaired

Total Loss

Other

If other, please explain.

Have you been provided a rental vehicle?

Yes

Where is your vehicle currently?

Describe your injuries suffered from the accident:

Was an ambulance called to the scene?

Yes

Were you taken to a hospital by ambulance?

Yes

What ambulance provider?

List all medical providers seen since the accident and approximate dates seen:

Prior to this accident have you ever injured or sought medical treatment for the same or similar body parts injured in this accident?

Yes

Have you been involved in any prior insurance claims, including worker’s compensation claims? Y/N If yes, please explain providing approximate dates:

Have you missed work due to your injuries from this accident?

Yes

Provide the name of the medical provider, if any, who excused you from work

Where are you employed?

How long employed at current employment?

Salary/Wages?

What is your job title?

What are your job duties?

Name of your immediate supervisor

At fault party’s auto insurance information:

At Fault Party's Name

Insurance Company

Adjuster name

Claim Number

Adjuster Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Adjuster phone number

Adjuster fax number

Your auto insurance information:

Insurance Company

Policy Number

Insurance agent name

Insurance agent phone number

Insurance agent address

Street Address City State / Province / Region ZIP / Postal Code Country

If a claim has been made to your auto insurance company, please provide the following:

Adjuster name

Claim Number

Adjuster Address

City State / Province / Region ZIP / Postal Code Country

Adjuster phone number

Adjuster fax number

Your health insurance information:

Health Insurance Company

Subscriber ID

Group ID:

Do you receive Medicare?

Yes

Medicare Number and Info

Do you receive Medicaid (Soonercare)?

Yes

Medicaid Number and Info

Did you take photos of the damage to your vehicle?

Yes

Did you take photos of the accident scene?

Yes

Did you take photos of your injuries?

Yes

Photo Uploads

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

You may upload multiple images here, although file size may be limited. Please only upload jpg, gif, png, or pdf format.

Any additional information regarding your case not already covered?

How did you hear about our law office?

Name

This field is for validation purposes and should be left unchanged.

GOROSPE LAW GROUP

The Gorospe Law Group Personal Injury Law Firm in Tulsa is experienced in all types of personal injury areas including car accidents, motorcycle accidents, commercial trucking accidents, premise liability, medical malpractice and more.

CONTACT US

1825 E 15th St
Tulsa, OK 74104
Phone: (918) 582-7775
Web: Gorospe Law Group

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Motor Vehicle Accident Intake Form

At fault party’s auto insurance information:

Your auto insurance information:

If a claim has been made to your auto insurance company, please provide the following:

Your health insurance information:

GOROSPE LAW GROUP

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