PERSONAL INJURY QUESTIONNAIRE FOR BANKRUPTCY

NAME:                                                                                 CH 7 CASE NO.                                               

ADDRESS:                                                                                                                                                     

CITY: STATE: ZIP:                                                                                                                                        

HOME PHONE:                                                                   OFFICE PHONE:                                               

DOB:                                                                                    YOUR SS#:                                        

MARITAL STATUS:                              ;                              SPOUSE DOB:                                   

NATURE OF ACCIDENT : Circle All Applicable

                    WERE YOU INJURED IN AN ACCIDENT IN THE LAST THREE (3) YEARS:

                    ( ) NO                                     ( ) YES

                    DID YOU COMMENCED A CLAIM OR LAWSUIT?

                    ( ) NO                                     ( ) YES

ARE YOU PRESENTLY A PARTY TO AN EXISTING CLAIM OR LAWSUIT FOR PERSONAL INJURIES?

                    ( ) NO                                     ( ) YES

IF CLAIM IS STILL PENDING PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER OF YOUR ATTORNEY HANDLING PERSONAL INJURY CLAIM OR LAWSUIT:

                                                                                                                                    

                                                                                                                                    

                                                                                                                                    

                    IF CLAIM IS STILL PENDING, HAVE DEPOSITIONS OR EBTs BEEN CONDUCTED?

                    ( ) NO                                    ( ) YES

WHAT TYPE OF ACCIDENT: Circle One or More

AUTOMOBILE                  SLIP & FALL                WORK-RELATED          OTHER                                         

DATE OF ACCIDENT:                                      TIME OF DAY:                             

AUTOMOBILE CASE, ANSWER ALL ITEMS

WERE YOU: ( )-DRIVER         ( )-PASSENGER              ( )-PEDESTRIAN

NAME OF INSURANCE COMPANY OF THE CAR YOU WERE IN AT TIME OF ACCIDENT:_________________________________________

                    POLICY #:

                    NAME AND ADDRESS OF OWNER OF CAR YOU WERE IN:

                    YEAR/MAKE/MODEL OF CAR YOU WERE IN AT TIME OF ACCIDENT:

NAME OF INSURANCE COMPANY OF THE DEFENDANT'S CAR:

                    POLICY #/CLAIM # OF DEFENDANT'S INSURANCE COMPANY:

                    YEAR/MAKE/MODEL OF CAR YOU WHICH STRUCK YOU OR YOUR VEHICLE:

WERE THERE ANY WITNESSES? ( ) NO             ( ) IF YES, NAMES & ADDRESSES:

NUMBER OF PEOPLE IN YOUR VEHICLE:                            OTHER VEHICLE:                                          

WEATHER CONDITIONS:                                                                                                             

ROAD CONDITIONS:                                                                                                                    

WERE YOU STRUCK FROM:

( )-BEHIND         ( )-FRONT              ( )-LEFT SIDE              ( )-RIGHT SIDE

DO YOU KNOW POLICY LIMITS OF NEGLIGENT DRIVER?                                 

DO YOU KNOW THE UNINSURANCE/UNDERINSURANCE LIMITS OF YOUR OWN AUTOMOBILE POLICY?                                                             

DESCRIBE NATURE AND EXTENT OF DAMAGE TO THE VEHICLES

IF SLIP AND FALL, ANSWER THE FOLLOWING COMPLETELY

WHERE DID THE INCIDENT OCCUR?

WHAT CAUSED YOU TO FALL?

WEATHER CONDITIONS:                                                                                                         

GROUND CONDITIONS:                                                                                                           

LIGHTING CONDITIONS:                                                                                                         

DESCRIBE HOW THE INCIDENT OCCURRED:

WERE YOU KNOCKED UNCONSCIOUS? ( )-NO    ( )-YES. IF YES, FOR HOW LONG?                         

WERE THE POLICE NOTIFIED? YES-( )                  NO-( )

DID AN AMBULANCE ARRIVE AT THE ACCIDENT SCENE?                                                                  

DID YOU RECEIVE TREATMENT AT THE ACCIDENT SCENE?                                                               

WERE YOU TRANSPORTED BY AMBULANCE TO THE EMERGENCY ROOM FROM THE SCENE OF THE ACCIDENT?             YES-( )                  NO-( )

        WHERE WERE YOU TAKEN AFTER THE ACCIDENT?

        WERE YOU ADMITTED TO A HOSPITAL?:( )-NO ( )-YES, NAME OF HOSPITAL                             

LENGTH OF ADMISSION                                                                                                       

WHAT INJURIES DID YOU SUSTAIN?

DID YOU HAVE ANY PHYSICAL COMPLAINTS BEFORE THE OCCURRENCE?( )-YES          ( )-NO

IF YES, PLEASE DESCRIBE IN DETAIL:

DID YOU LOSE TIME FROM WORK AS A RESULT OF THIS ACCIDENT?( )-YES              ( )-NO

IF YES, PLEASE COMPLETE THE FOLLOWING:

        A-HOW MANY LOST DAYS:                                              

        B-TYPE OF EMPLOYMENT:

        C-SALARY:

        D-ARE YOU OR WERE YOU COMPENSATED FOR TIME LOST FROM WORK?( )-YES ( )-NO

                -IF YES, WHAT TYPE OF COMPENSATION?                                                              

HAVE YOU BEEN TREATED BY OTHER HEALTHCARE PROVIDERS SINCE THE ACCIDENT?

( )-YES     ( )-NO        IF YES, PLEASE LIST DOCTOR'S NAME AND ADDRESS:

WHAT TYPE OF TREATMENT DID YOU RECEIVE?

FOR HOW LONG A PERIOD DID YOU RECEIVE TREATMENT?

ARE YOU PRESENTLY UNDER ACTIVE TREATMENT? WITH WHOM? IF NOT, WHEN WAS THE LAST TIME YOU WERE UNDER ACTIVE TREATMENT?

HAS SURGERY BEEN INDICATED FOR INJURIES SUSTAINED IN THIS ACCIDENT? ( )-YES ( )-NO

DO YOU HAVE ANY CONGENITAL (FROM BIRTH) FACTORS WHICH RELATE TO THIS PROBLEM?

( )-YES ( )-NO

IF YES, PLEASE DESCRIBE IN DETAIL:

DO YOU HAVE ANY PREVIOUS ILLNESSES WHICH RELATE TO THIS CASE?  ( )-YES ( )-NO

IF YES, PLEASE DESCRIBE IN DETAIL:

HAVE YOU EVER BEEN INJURED IN AN PREVIOUS ACCIDENT?( )-YES ( )-NO

IF YES, PLEASE DESCRIBE, INCLUDING DATE(S) AND TYPE(S) OF ACCIDENTS, AS WELL AS INJURY(IES) RECEIVED.

DID YOU HAVE ANY ACTIVITY RESTRICTIONS AS A RESULT OF THE MORE RECENT INJURY?

( )-YES ( )-NO,         IF YES, PLEASE DESCRIBE IN DETAIL:

DATE

                                                                                        SIGNATURE: