MVA Intake Form Minor

Guardian’s Full Legal Name:*

Child’s Full Legal Name:*

Date of Collision

Your Auto Insurance

Phone No

Other Driver's Name

Other Driver’s Insurance

Claim No

Adjuster Name

Phone No

To the best of your knowledge, please describe what happened during the accident?

Brief Description of Child’s Injuries

Was a police report filed?

Yes
No

What police department?

Report No

Was 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

Name

Phone No

Did the child see a chiropractor after the collision?

Yes
No

Name

Phone No

Has the child been referred to a specialist?

Yes
No

Name

Phone No

Is the child currently taking any medications as a result of this injury?

Yes
No

Medications

What activities has the child been unable to do since the accident?

Child’s Date of Birth:

Child’s Social Security Number:

Policy No:

Group No:

Guardian’s Email:*

Guardian’s Cell Phone:

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Phone No

MINOR
Motor Vehicle Collision Information

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MINOR Motor Vehicle Collision Information

MINOR
Motor Vehicle Collision Information