4 When did it happen? —Please choose an option— In the last 30 days 1-6 months ago 6-12 months ago Over a year ago
4-1 Were you injured in the accident? —Please choose an option— Yes No
7 I was at fault: —Please choose an option— No Passenger Yes
8 Did you go to the doctor? —Please choose an option— Yes No
9 My total medical expenses have been (including money you paid and paid by insurance): —Please choose an option— $0 - $8,000 $8,000 - $16,000 Over $16,000 Unsure
10 The amount of money I lost from work is: (If you missed work because of your injuries, the total amount of lost income.) —Please choose an option— $500 - $5,000 $1,000 - $5,000 Over $5,000 Unsure
11 The amount of future income I will lose is: (If you will be missing work in the future because of your injuries, the projected amount of your future income loss.) —Please choose an option— $500 - $5,000 $1,000 - $5,000 Over $5,000 Unsure
12 I will have future medical bills of: (If you will require medical care in the future, the projected cost for such care.) —Please choose an option— $500 - $5,000 $5,000 - $10,000 Over $10,000 Unsure
16 My suffering will remain permanent: —Please choose an option— Yes No
17 My physician has clearly indicated I will have future problems: —Please choose an option— Yes No
18 I have broken bones: —Please choose an option— Yes No
19 Ive had surgery or need surgery: —Please choose an option— Yes No
20 My "Pain and Suffering" is: —Please choose an option— Hard Tissue Injuries (Can be detected by medical examination) Soft Tissue Injuries (sprains and strains)
21 Are you represented by a lawyer for this accident? —Please choose an option— Yes No