Please complete the following questionnaire regarding your Motor Vehicle Accident case.

MVA Questionnaire

Please complete this Questionnaire regarding your motor vehicle accident case.

"*" indicates required fields

Personal Information

Name*
Date of Birth*
Address*
DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.

Employment Information

Accident Information

Please provide a brief description of what happened. (Ex: I was stopped at a red light and another driver rear-ended me.)
Please provide as much detail as possible, including the city or county, street name, date and approximate time of the accident.

Auto Insurance

(Ex: USAA, 00012345)

Health Insurance

Select Your Health Insurance Provider(s)*
If you selected Private Insurance above, please include the name of your provider. If you have supplemental coverage or multiple providers, please specify which provider is associated with each Member ID Number. (Ex: Medicare 0012345, Humana 0098765)

Medical Treatment & Injury Information

This includes Emergency Room, Urgent Care, Chiropractor, Orthopedic Specialist, Physical Therapy, Etc.
List of Medical Providers*
Enter the name and location of each facility/provider that you have treated with. Use the “plus” button to add additional providers. It is VERY IMPORTANT that you list ALL medical providers you have treated with. (Ex: Emory Hospital Midtown, 550 Peachtree St NE, Atlanta, GA)
Enter a brief description of your injuries. (Ex: Lower back pain, headaches, broken arm, Etc.)
Please be truthful in your response to this question. Your answer is VERY important and necessary for us to give your case the best outcome. This information will not be shared with anyone outside our law firm.
(Ex: Rear-ended in 2010, back injury, other driver’s insurance paid for my repairs.)
This field is for validation purposes and should be left unchanged.