Personal injury attorney Colorado Springs

Personal Injury Evaluation Form

This InjuryEvaluation.com form is used to provide information to Robert Anderson, attorney at law, P.C., to permit an initial evaluation of your claim. Information obtained is not used for any other purpose. All information received is kept strictly confidential. No information is sold or given to other entities.

There are five sections to the form. The form takes about ten minutes to complete. Most people will not have all the information at hand to answer each question. Forms submitted dealing with recent accidents may have MOST of the information boxes blank. That is fine. Fill out and submit the form as completely as possible now with the information you do have. It can be supplemented later if need be once an initial review is completed.

The form is designed to answer questions about one person. There may be other people such as family members or friends who were also injured in the same accident. If so, please complete the form for the one person answering and simply advise at the end of the form in the "Additional Information / Issues, Concerns" box how many others were injured in the accident and their relationship to you. Follow–up can then be directed by the attorney concerning the other injured people.

Submission of this form does not create an attorney–client relationship.

Section 1 – Accident Information

I am responding to these questions with regard to:
my own injuries
someone else's injuries
The other person's relationship to me is:

1. Your role in the accident:

2. Number of vehicles involved in accident:

3. Vehicle description:

Vehicle 1: (the one you were in, or that struck you if you were a pedestrian)

Vehicle 2:

Vehicle 3:

4. Time, date, and Location of accident:

Date/Time of accident:

month	day	year	approximate time

Location of Accident:

state	city	street

		at closest intersection with

Vehicle 1(the one you were in, or that struck you if you were a pedestrian)
Road vehicle was on:
Direction of travel:
Movement of vehicle:

Vehicle 2
Road vehicle was on:
Direction of travel:
Movement of vehicle:

Vehicle 3
Road vehicle was on:
Direction of travel:
Movement of vehicle:

5. Description of how the accident happened:

Who do you believe to be at fault and why?

(why?)

Were police called?
Yes No

Was anyone given a ticket?
Yes No

Who got the ticket and what was it for (if known)?

Were all drivers identified?
Yes No

Was the at–fault driver identified?
Yes No

Any indication drugs or alcohol were involved?
Yes No
By whom?

Any indication that any driver was driving in connection with their employment and/or for any governmental entity at the time of the accident?
Yes No

Section 2 – Losses – if known

How much property damage was done to the vehicles?

Vehicle 1
Describe:
Estimated dollar amount:
Was vehicle totaled or repaired?
Who paid for vehicle repair?

Vehicle 2
Describe:
Estimated dollar amount:
Was vehicle totaled or repairable?

Vehicle 3
Describe:
Estimated dollar amount:
Was vehicle totaled or repairable?

Have you incurred or will you incur damages for:

Medical expense?	Yes No	Amt. if known
Lost wages?	Yes No	Amt. if known	Amt. of time missed or expected to be missed.
Personal property?	Yes No	Amt.	Describe:
Rental car?	Yes No	Amt.	Number of days:
Other	Yes No	Amt.	Describe:

Section 3 – Injuries

Were you or anyone involved in the accident injured?
Yes No
Who?

Did the accident involve death?
Yes No

Describe the injuries:
		Description
Fracture:
Cuts or bruising:
Back pain:
Neck pain:
Headaches:
Numbness/tingling/ shooting pains:
Knee:
Shoulder:
Hand:
Wrist:
Elbow:
Jaw pain/popping, clicking:
Dental:
Loss of consciousness:
Memory Difficulties:
Confused or slow thinking:
Internal injuries:

Have you had any previous or subsequent injuries to the areas of the body injured in this accident?
Yes No
(describe)

Section 4 – Treatment Information – if known

I am in pain, but have not yet seen a doctor.
Yes No

Was an ambulance called?
Yes No

Did you go to the emergency room?
Yes No

How long were/have you been in the hospital?

Have you followed up with care for injuries caused by the accident?
Yes No

If so, with whom?
	:family physician
	:chiropractor
	:physical medicine/rehabilitation doctor
	:neurologist
	:orthopedic doctor
	:surgeon
	:psychologist/psychiatrist
	:dentist/TMJ specialist
	:physical therapist
	:massage therapist

Were there any diagnostic tests run? Yes No
	Tests	Results
X–rays:
CT scan:
EMG/NCV:
MRI:
Other:

Section 5 – Insurance Information – if known

Type of insurance you have:
health insurance	Yes No
Medicaid/Medicare	Yes No
military medical care available	Yes No

Are you eligible for Workman's Compensation benefits?
Yes No

Were you an employee injured while performing work–related duties?
Yes No Not sure

Company insuring the vehicle of driver number:		(other)
1.
2.
3.

If you did not own the vehicle you were in, did you have vehicle insurance in your own name covering you at the time of the accident?
Yes No (If yes, which company?)

At the time of the accident, were you residing with a relative who had vehicle insurance in effect regardless of whether you were listed as an insured?
Yes No (If yes, which company?)

Additional Information / Issues, Concerns

Please submit any additional information that may help evaluate your claim. Also submit any issues or concerns you may have.

Name:
E–mail:
Home phone:
Work phone:
Have you settled any claims that you may have stemming from this accident? Yes No Are you currently represented by an attorney on this matter? Yes No Are you satisfied with the representation you are getting? Yes No N/A How did you hear about this Web site? Other

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