Automobile Accident

We are committed to your privacy, information on this form will be sent through a secure server connection, for more information please read our Privacy Statement.

Been injured and Not sure what to do? Please read our Frequently Asked Questions for helpful ideas.

Personal Information

Name
Email Address
Address
City
State
Zip
County
Home Phone
Work Phone
Date of Birth
Social Security Number
Number of Children
How did you hear of Merkle Law Firm?

Your Injuries

Did you go to the emergency room?
 Yes
 No
If yes, where?
Did you go in an ambulance?
 Yes
 No
What are your injuries?
Please list all doctors/ medical providers that you have seen for your injuries
What is the total amount of your medical bills to date?
Have any of them been paid yet?
 Yes
 No
By who/ what insurance company?

Work Losses

Have you lost any time from work?
 Yes
 No
Hours/days lost from work?
Employer's name
What is your hourly pay rate?
Has your doctor given you any work restrictions?
 Yes
 No
If Yes, what are they?

Other Injuries

Have you had any other similar injuries?
 Yes
 No
If yes, please describe:
Have you ever had any other insurance claims?
 Yes
 No
If yes, please describe:
Have you had any other accidents?
 Yes
 No
If yes, please describe:

Your Injuries

Have any of your activities been interrupted due to this accident?
 Yes
 No
If Yes, please describe. Note each activity and if you can't do or can do with pain:
Witnesses to activity/lifestyle changes

If you have any pictures showing the injured person in action before the injury please provide them.


Insurance Information

Your Auto Insurance

Company Name
Adjuster
Address
Phone Number
Insurance Claim Number

Your Health Insurance

Company Name
Adjuster
Address
Phone Number
Insurance policy number
Insurance claim number

Defendant's Insurance

Company Name
Adjuster
Address
Phone Number
Insurance policy number
Insurance claim number

Additional Comments

Comments