• IMPORTANT: We must have the information in this survey to complete your claim! Please complete this survey and return it to us within the next 10 days.
  • PRE-ACCIDENT SURVEY #1

  • 1. EMPLOYMENT HISTORY

  • 1.1 Employment at the Time of Your Accident

  • 1.2 Five Year Employment History

  • 1.3 Spouse‚Äôs Employment

  • 2. HEALTH AND HOSPITALIZATION HISTORY

  • 2.1 Past Hospitalizations Before Your Accident

  • If yes, please complete the following:
  • 2.2 Past Illnesses

  • If yes, please complete the following:
  • 2.3 Accidents, Broken Bones or Injuries Before This Accident

  • If yes, please furnish the following information:
  • 2.4 Past Medical/Dental Information

  • In the FIVE YEARS BEFORE YOUR ACCIDENT, who has been your regular family doctor and dentist that you have consulted when you needed medical attention? If more than one doctor, dentist, osteopath, chiropractor, or other physician has been used by you, please indicate below.
  • If yes, please name each drug or medication and its purpose:
  • 3. INSURANCE INFORMATION

  • 3.1 Medical Insurance

  • If so, please furnish the following information:
  • Have you made any claim for payment of your accident-related medical bills from:
  • If any of your accident related medical bills been paid by a health insurance company, Medicaid, Medicare or any person other than yourself, please furnish the following information:
  • If yes, please furnish the following information: