1. Did the accident occur within the last three years? Yes
2. Were you injured? Yes
3. Is the other party at fault? Yes
4. Have you been contacted by the other party’s insurance company? Yes
5. If so, did you give a recorded statement? Yes
or
i. What is the date of the incident?
Date:
ii. What was the first date you received medical treatment?
Date:
iii. Who is your primary care physician or other medical provider?
iv. Are you still receiving medical treatment for your injury?
Yes
v. What is the police incident or report number?
vi. Tell us about the accident, the other parties involved, your injuries, the impact of the accident on your life and activities, and the steps you have taken and treatment you have received to overcome your injuries
Copyright 2009 EMERY | REDDY, PLLC • 600 Stewart Street Suite 1100, Seattle, WA 98101 • 206 442 9106
