Form

Law Offices of Morgan D. King
CONFIDENTIAL ACCIDENT INFORMATION FORM
PLEASE FILL OUT THE BELOW FORM AS BEST YOU CAN. WHEN YOU CLICK THE "SUBMIT" BUTTON AT THE BOTTOM IT WILL BE SENT TO MORGAN KING BY EMAIL
1. DATE OF ACCIDENT:
2. YOUR NAME:
3. HOME PHONE NO.
4. WORK PHONE NO.
5. CELL PHONE NO.
6. EMAIL ADDRESS:
7. YOUR DATE OF BIRTH:
8. YOUR CURRENT CITY & STATE OF RESIDENCE
9. CITY AND STATE WHERE ACCIDENT HAPPENED:
10. TYPE OF ACCCIDENT:
11. WERE YOU MARRIED AT TIME OF ACCIDENT?

YES & LIVING TOGETHER YES BUT SEPARATED NO
12. IF MOTOR VEHICLE WHAT KIND OF VEHICLES INVOLVED?

NOT APPLICABLE BIG RIG OTHER TRUCK OR SUV CAR MOTORCYCLE PEDESTRIAN BICYCLE TRAILER BOAT AIRPLANE
13. BRIEFLY DESCRIBE HOW ACCIDENT HAPPENED:
14. WAS YOUR VEHICLE INSURED AT TIME OF ACCIDENT:

YES NO UNK. NOT APPLICABLE
15. WERE YOU INJURED?

YES NO
16. IF INJURED BRIEFLY DESCRIBE YOUR INJURIES:
17. DID YOU SPEND OVERNIGHT AT HOSPITAL BECAUSE OF YOUR INJURIES?

YES NO
18. ARE YOU STILL EXPERIENCING PAIN?

YES NO NOT APPLICABLE
19. ARE YOU STILL BEING TREATED?

YES NO NOT APPLICABLE
20. WHAT KIND OF TREATMENT DID YOU NEED?

SURGERY MEDICINE THERAPY OTHER
21. WAS AN ACCIDENT REPORT DONE BY LAW ENFORCEMENT?

YES NO UNK. NOT APPLICABLE
22. WHO DOES REPORT SAY WAS AT FAULT?

OTHER DRIVER ME BOTH OF US OTHER PERSON OR ENTITY UNK. NOT APPLICABLE
23. WERE PHOTOGRAPHS TAKEN OF ACCIDENT SCENE?

YES NO UNK. NOT APPLICABLE
24. WERE PHOTOGRAPHS TAKEN OF YOUR INJURIES?

YES NO UNK. NOT APPLICABLE
25. OTHER MEMBER(S) OF YOUR FAMILY WHO WERE INJURED:

CHILD OR CHILDREN UNDER 18 ADULT CHILD OR CHILDREN SPOUSE OTHER RELATIVE NONE
26. WERE X-RAYS TAKEN OF YOUR INJURIES?

YES NO UNK. NOT APPLICABLE
27. WAS YOUR VEHICLE INSURED AT TIME OF ACCIDENT?

YES NO UNK. NOT APPLICABLE
28. WAS THE OTHER DRIVER OR RESPONSIBLE PARTY INSURED?

YES NO UNK. NOT APPLICABLE
29. HAVE YOU LOST INCOME DUE TO YOUR INJURIES?

YES NO MAYBE NOT APPLICABLE
30. HAVE YOU BEEN CONTACTED BY OTHER PARTY'S INSURANCE AGENT?

YES NO UNK. NOT APPLICABLE
31. NAME OF OTHER PARTY'S INS. AGENT:
32. OTHER PARTY'S INS. AGENT PHONE NUMBER:
HOW DID YOU FIND OUT ABOUT ME?

REFERRED BY AN EX-CLIENT OF MR. KING REFERRED BY ANOTHER ATTORNEY REFERRED BY ANOTHER PROFESSIONAL INTERNET SEARCH WORD OF MOUTH KNOW MR. KING PERSONALLY OTHER SOURCE
33. IF OTHER PARTY WAS A VEHICLE WAS IT A BUSINESS VEHICLE?

YES NO UNK. NOT APPLICABLE
34. NAME OF OTHER PARTY BUSINESS (IF APPLICABLE)
35. HAVE YOU FILED A LAWSUIT IN THIS CASE?

YES NO NOT APPLICABLE
36. WAS THE OTHER PARTY A PUBLIC ENTITY OR OWNED BY A PUBLIC ENTITY?

YES NO UNK. NOT APPLICABLE
IF ACCIDENT REPORT WAS DONE WHICH ENTITY PREPARED IT?

CITY POLICE COUNTY HIGHWAY PATROL PRIVATE SECURITY OTHER NOT APPLICABLE
Copy figures at right into box below and hit "Submit"*
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CONFIDENTIAL ACCIDENT INFORMATION FORM