Pre-Accident Survey #1 Date of Inquiry: Client:IMPORTANT: We must have the information in this survey to complete your claim! Please complete this survey and return it to us within the next 10 days. PRE-ACCIDENT SURVEY #11. EMPLOYMENT HISTORY1.1 Employment at the Time of Your AccidentEmployer:Address Street Address: City: State: Zip: Job TitleDate employment began: Salary Rate of Pay: $Per:How many hours per week:Hourly: $Per:How many hours per week:Benefits:Amount you earned in the last full year before your injury: $Did you receive a W-2:YesNoHave you filed Income Tax Returns for the last 5 years:YesNoDo you have copies:YesNo1.2 Five Year Employment HistoryMost recent employer BEFORE your current one:Employer:Address Street Address City State / Province / Region ZIP / Postal Code Salary Rate of Pay: $Per:How many hours per week:Hourly: $Per:How many hours per week:Benefits:1.3 Spouse’s EmploymentIs your spouse presently employed:First ChoiceSecond ChoiceThird Choice2. HEALTH AND HOSPITALIZATION HISTORY 2.1 Past Hospitalizations Before Your AccidentWere you EVER AT ANYTIME received treatment at a hospital BEFORE this accident for any reason:YesNoIf yes, please complete the following:Most recent hospital treatment BEFORE the accident:Address Street Address City State / Province / Region ZIP / Postal Code Reason for Hospital treatment:Length of Hospital treatment: (From) To: Next hospital treatment BEFORE the accident:Address Street Address City State / Province / Region ZIP / Postal Code Reason for Hospital treatment:Length of Hospital treatment: (From) To: 2.2 Past IllnessesBEFORE this accident, did you have had ANY long-lasting, chronic or serious illnesses for which you sought medical treatment?YesNoIf yes, please complete the following:Doctor:City:StateNature of Illness:Date Doctor:City:StateNature of Illness:Date Doctor:City:StateNature of Illness:Date 2.3 Accidents, Broken Bones or Injuries Before This AccidentBEFORE this accident did you have any injuries or medical conditions of any kind which required medical attention?YesNoIf yes, please furnish the following information: DoctorCity:State:Date Nature of Accident:Injury:DoctorCity:State:Date Nature of Accident:Injury:DoctorCity:State:Date Nature of Accident:Injury:2.4 Past Medical/Dental InformationIn the FIVE YEARS BEFORE YOUR ACCIDENT, who has been your regular family doctor and dentist that you have consulted when you needed medical attention? If more than one doctor, dentist, osteopath, chiropractor, or other physician has been used by you, please indicate below. Primary Care Doctor:Dates Seen:throughAddress Street Address City State / Province / Region ZIP / Postal Code Reason(s) for treatment:Dentist:Dates Seen:throughAddress Street Address City State / Province / Region ZIP / Postal Code Reason(s) for treatment:Other Dr. or Health Care ProviderDates Seen:throughAddress Street Address City State / Province / Region ZIP / Postal Code Reason(s) for treatment:Did you use any drugs or medications regularly (more than one refill) BEFORE your accident: Yes No If yes, please name each drug or medication and its purpose: Drug:Purposes:Drug:Purposes:Drug:Purposes:Drug:Purposes: Auto Date Reason: Life Date Reason: Health Date Reason:3. INSURANCE INFORMATION 3.1 Medical InsuranceDo you have any medical insurance policies, including any medical insurance through your employment, or a private medical policy: Yes No If so, please furnish the following information: Name of Insurance Company:Address Street Address City State / Province / Region ZIP / Postal Code Insurance Agent, if any:Policy Number:Who pays for this coverageHave you made any claim for payment of your accident-related medical bills from: Your medical insurance: Yes No Other insurance company: Yes No Medicaid/Medicare: Yes No Other sources: Yes No If any of your accident related medical bills been paid by a health insurance company, Medicaid, Medicare or any person other than yourself, please furnish the following information: Name of entity paying bills:Name of entity paying bills:Name of entity paying bills:Do you have any insurance of any kind which would provide disability payments Yes No If yes, please furnish the following information: Name of Insurance Company:Address Street Address City State / Province / Region ZIP / Postal Code Insurance Agent:Phone No:CAPTCHA
