Pre-Accident Survey Form #2 Date of Injury 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 #21. MILITARY HISTORY 1.1 Military BackgroundHave you ever been in the military service: Yes No If yes, dates:ToType of discharge received: Honorable Dishonorable Others Do you have a Veterans Administration Number: Yes No If yes, number:Have you ever been rejected for military service because of physical or other reasons: Yes No If yes, please explain:2. EDUCATIONAL BACKGROUND 2.1 Schools / TrainingHigh SchoolCity:StateYears Attended: (From) To: Graduated Yes No College-University:City:StateYears Attended: (From) To: Graduated Yes No Technical TrainingCity:StateYears Attended: (From) To: Graduated Yes No 3. LITIGATION HISTORY 3.1 Police RecordHave you ever been arrested? Yes No If yes, please give the following: Date Country:State:Criminal Charge:Have you ever been convicted? Yes No If so of what crime?Is there now or has there ever been any restriction on your driver's license Yes No If yes, please give the detailsDate of Suspension/Revocation: Reason:Has your driver's license ever been suspended or revoked? Yes No If yes, please give the detailsDate of Suspension/Revocation: Date: Reason:Have you ever received any traffic tickets: Yes No If yes, please furnish the following information: Nature of Traffic Ticket:Date What was done about it:Nature of Traffic Ticket:Date What was done about it:Nature of Traffic Ticket:Date What was done about it:4. CLAIMS AND COURT CASES 4.1 Claims & Court CasesHave you ever made a claim for a work-related injury at any time: Yes No If yes, complete following:Date Injury(s)EmployerAddress Street Address City State / Province / Region ZIP / Postal Code Settlement received or outcome:Have you ever filed a claim for Social Security Disability benefits: Yes No If yes, complete following:Date Claim Number:Injury of medical condition you claimed was disabling:Outcome:Have you ever made a claim as a result of an automobile accident: Yes No If yes, complete following:Date City:State:Description of accident:Injuries you received:Amount received or outcome of claim:Have you ever received a veteran's pension or benefits: Yes No If yes, complete following:Date Claim Number, if any:Reason:Outcome of claim:Have you made any claims at any time for benefits from any other source?(Disability insurance, unemployment benefits, etc.) Yes No If yes, complete following:Benefits sought:Date ResultBenefits sought:Date Result5. RELIGIOUS/FRATERNAL/SPECIAL AFFILIATIONS 5.1 Religious and Fraternal InformationReligious affiliation:Name of your clergyman:Please list any memberships in Church Organizations, Lodges, Fraternal Organizations, Other Memberships, Public Offices Held, etc. (Include past or present affiliations) Organization:Organization:Organization:Member of any Union: Yes No If yes, please list: NameLocal Number:6. HOBBIES AND SPECIAL INTERESTS6.1 Hobbies / Special InterestsPlease list any Hobbies you have:Please list any Special Interests you have:CAPTCHA
