MINOR Motor Vehicle Collision Information Home / MVA Intake Form Minor Guardian’s Full Legal Name:*Child’s Full Legal Name:*Date of Collision MM slash DD slash YYYY Your Auto InsurancePhone NoOther Driver's NameOther Driver’s InsuranceClaim NoAdjuster NamePhone NoTo the best of your knowledge, please describe what happened during the accident?Brief Description of Child’s InjuriesWas a police report filed? Yes No What police department?Report NoWas the child transported by ambulance? Yes No Which one?Did the child go to the hospital emergency room? Yes No Which one?Was the child admitted into the hospital following the ER visit? Yes No Did the child see his/her personal physician after the collision? Yes No NamePhone NoDid the child see a chiropractor after the collision? Yes No NamePhone NoHas the child been referred to a specialist? Yes No NamePhone NoIs the child currently taking any medications as a result of this injury? Yes No MedicationsWhat activities has the child been unable to do since the accident?Child’s Date of Birth: MM slash DD slash YYYY Child’s Social Security Number: Health Insurance Medicare Medicaid Military Insurance None Policy No:Group No:Guardian’s Email:* Guardian’s Cell Phone:Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactPhone No 29149
