West Palm Beach car accident Client Interview Questionnaire

West Palm beach car accident Client Interview Questionnaire: Automobile Accident Cases

Client Interview Questionnaire

The Automobile Accident

1. Date of the accident: _________________________________

Day of the week: ______________________________________

Time of day: __________________________________________

Weather conditions: ___________________________________

2. Describe in detail the location of the accident (include in your answer proximity to driveways, intersections, traffic signs, homes, businesses or other fixed objects).

_______________________________________________________

3. Describe (a) where you were going at the time of the accident, (b) where you were coming from, (c) if you were the driver of the vehicle, and (d) how many times you have driven along the route which you were traveling at the time of the accident.

_______________________________________________________

4. Describe in detail how the accident happened. Include in your answer (a) distances, (b) speeds, (c) road or weather conditions, (d) any defects in the vehicles or road, (e) whether the highway was marked or divided, (f) any visual obstructions, (g) the presence of any skid marks, (h) a notation of any unusual sounds or noises heard, and (i) whether you used directional signals.

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5. Did you have a conversation with the driver of the other vehicle? If so, were any statements made as to who was at fault? What statements?

_______________________________________________________

6. Did you have any other conversations at that time or subsequent to the accident with the driver, his passenger, or any other party? If so, specify the name of the person, his address and the substance of the conversation.

_______________________________________________________

7. Did the police investigate the accident? If so, did you give a statement to the police? If so, state in detail exactly what you told the police. Also, state in detail any other statements you overheard being given to the police.

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8. Who called the police?

_______________________________________________________

9. Was anyone else injured in the accident? If so, who was injured and what was the extent of his injuries?

_______________________________________________________

_______________________________________________________
10. Did an ambulance arrive at the scene of the accident? If so, who called the ambulance, and when did it arrive? Did anyone accompany you to the hospital? If so, give his name and address.

_______________________________________________________

11. Identify all witnesses known to you, giving names, addresses and any relationship to you.

_______________________________________________________

12. Did you have any discussions with any of the witnesses at the scene of the accident? If so, with whom did you speak and what was said?

_______________________________________________________

13. Give the address of the defendant(s). Include both the owner and the operator of the other vehicle, if known.

_______________________________________________________

14. Give the name and address of the defendant's insurance carrier and specify how you acquired this information.

_______________________________________________________

15. Give the name and address of the defendant's insurance adjuster and specify how you acquired this information.

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16. Have any statements, either oral or written, been given by you or anyone on your behalf to the defendant's insurance carrier or anyone else representing the defendant? If so, give the substance of the statement, when you gave it, where you gave it and to whom you gave it.

_______________________________________________________

17. Do you have a copy of the statement(s)?

_______________________________________________________

18. Were any photographs taken of the scene of the accident, the vehicles involved, or the persons injured? If so, identify the subject of each photograph and indicate when it was taken, where and by whom.

_______________________________________________________

19. Identify all persons currently having possession of any such photographs.

_______________________________________________________

20. Was the vehicle you were riding in damaged? If so, describe what portions of the vehicle were damaged and the estimate of any cost of repair of which you are aware.

_______________________________________________________

21. Has the vehicle in which you were riding been repaired? If so, indicate who performed the repairs, who paid for them, the cost of the repairs and whether you have a copy of the invoice of the repair costs.

_______________________________________________________

22. Who were the actual owners of the vehicles involved in the accident?

Other vehicle: ________________________________________

Your vehicle: _________________________________________

Describe the make, model, year, and license number of each vehicle.

Other vehicle: ________________________________________

Your vehicle: _________________________________________

When was the vehicle in which you were riding purchased, from whom and at what price?

_______________________________________________________

23. Were there any defects in or problems with your vehicle or the vehicle you were riding in? If so, describe.

_______________________________________________________

24. Did the vehicle you were riding in have a current inspection sticker at the time of the accident? If so, state the date and by whom the sticker was issued.

_______________________________________________________

25. Give the name and address of the insurance company insuring the vehicle you were in.

_______________________________________________________

26. Do you have a copy of the policy? _____________________

27. Are you a named insured under any automobile insurance policy? If so, identify the insurance company and the policy number.

_______________________________________________________

Provide a copy of the policy if available and if not available, provide the name of your agent so that we may obtain a copy of it.

_______________________________________________________

28. If you were hospitalized, give the names and addresses of all hospitals and the amount of total charges incurred.

_______________________________________________________

29. List the names and addresses of all doctors, nurses, and technicians who have treated you, the dates of the treatment received, and the charges incurred.

_______________________________________________________

30. Did the accident occur in the course of your employment?

_______________________________________________________

31. Were you driving the vehicle or were you a passenger in it?

_______________________________________________________

32. Have you applied for any medical or insurance benefits (including workers' compensation) as a result of the accident? If so, when and to whom did you apply, and what response to your application did you receive?

_______________________________________________________

33. Have you received any medical or insurance benefits (including workers' compensation) as a result of the accident? If so, who made the payments, when and in what amount were they made?

_______________________________________________________

34. Did you or the driver of your vehicle consume any alcohol prior to the accident? If so, identify what each of you was drinking, where each drink was consumed, with whom each of you was drinking, the amount that each of you had to drink, and how long prior to the accident each of you had your last drink.

_______________________________________________________

35. Did you or the driver of your vehicle take any medication or drugs before the accident? If so, identify the type of drug each of you took, who prescribed the medication, the dosage and how long before the accident each of you took the last dose.

_______________________________________________________

_______________________________________________________
_______________________________________________________

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36. If either you or the driver of your vehicle took any medication or drugs within the 24-hour period before the accident, state whether any physician had prescribed any medication or drugs for either of you which should have been taken at the time of the accident and, if so, identify the physician who prescribed the medication, the nature of the medication, the reasons it was prescribed and the reasons it was not taken.

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37. Did the driver of your vehicle have any restrictions on his driver's license? If so, state what they are.

_______________________________________________________

38. Were any persons charged with motor vehicle violations or criminal charges as a result of the accident? If so, who was and what were the charges?

_______________________________________________________

39. Has there been a resolution to the charges? If so, how were they resolved?

_______________________________________________________

40. Were you employed at the time of the accident? If so, identify your employer, the specific nature of your employment (including job duties) and your average weekly earnings at the time of the accident.

_______________________________________________________

41. Were you prevented from working as a result of any injuries you suffered in the accident? If so, how long were you out of work and on whose advice?

_______________________________________________________

42. If you did not actually lose any time from work as the result of your injuries, did any physician tell you not to work for any period of time? If so, identify the physician, the reason that you were told not to work and the reason that you worked despite these instructions.

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43. Describe all activities you typically engaged in which you were prevented from doing as a result of the accident.

_______________________________________________________

44. Provide the name of your spouse and the names and birth dates of your children.

_______________________________________________________

45. Describe any household tasks you typically performed which others had to perform because of any injuries you suffered in the accident.

_______________________________________________________

46. Provide the name of your health insurance carrier and list all medical bills it has paid.

_______________________________________________________
_______________________________________________________

_______________________________________________________

47. Identify any other source of payments for medical bills you have incurred.

_______________________________________________________

48. List all other expenses you have incurred as a result of the accident and which have not yet been reimbursed.

_______________________________________________________

All material contained in this site is for informational purposes only and is not meant to take the place of a licensed lawyer. Attempting to use this material to help yourself may result in irreparable harm to your case. Please consult a License Florida lawyer for help. Examples including case law, rules of procedure and satutory law are for demonstrative purposes and may not be Florida Specific. No attorney client relationship is formed unless we accept your case and you sign a contract.
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