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Motor Vehicle Crash Intake Form

Name *

Date of Birth

Cell Phone *

Home Phone

Work Phone

Email Address *

Street Address

City *

Province

Postal Code

If you are contacting us on behalf of someone else, please provide that person’s full name, date of birth and your relationship to that person

Date and time of motor vehicle collision (MVC) *

Location of the MVC (street and municipality) *

Description of what happened

Road conditions at time of the MVC

Weather at the time of the MVC

Did the police investigate the MVC? Yes No

Name of the police service that investigated

Did the police charge the other driver(s)? If yes, with what offence?

Did the police charge you? If yes, with what offence?

Were you working or in the course of your employment at the time of the MVC? Yes No

Describe your initial injuries from the MVC *

Did you go to the hospital immediately following the MVC? Yes No

Did you go by ambulance? Yes No

If you did not go to the hospital immediately following the MVC, what was the date that you first saw a medical professional for your MVC injuries? Who did you see or where did you go for medical treatment?

Do you currently receive medical treatment? If yes, please provide the names of all the medical professionals who provide you with treatment eg. family doctor, physiotherapist, chiropractor, psychologist, occupational therapist etc.

Describe your current symptoms *

Describe how your symptoms affect your day to day activities eg. work, housekeeping, caregiving, shopping etc.

Please provide details of any other medical conditions, injuries, accidents or pain problems in the past 5 years

Employment at the time of the MVC

What is your employment income per year

Did the injuries from the MVC cause you an inability to work? Yes No

If yes, describe the periods that you have been unable to work? *

If you are still working, do the injuries from the MVC interfere with your ability to do your employment tasks and duties? If yes, please explain.

Name of your automobile insurer

Have you applied to your automobile insurer for no-fault accident benefits? * Yes No

If not, why not?

If yes, please describe the benefits or treatments that your no-fault accident benefits insurer is paying eg. income replacement benefits, physiotherapy, chiropractic, occupational therapy etc.

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