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Attorney Douglas R. Horn
Attorney Laurie Del Percio
Advancing Driver Safety
Motor Vehicle Accidents
Motor Vehicle Accidents
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Motorcycle Accidents
Reckless Driving Accidents
Distracted Driving Accidents
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Delivery Truck Accidents
Motor Vehicle Child Injuries
Boating Accidents
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Work Injuries
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Industrial Accidents
Construction Accidents
Warehouse Accidents
Maximizing Injury Settlements
Track Record
Track Record
Motor Vehicle Cases
Other Injury Cases
Blog
Contact Us
About Us
About Us
Attorney Douglas R. Horn
Attorney Laurie Del Percio
Advancing Driver Safety
Motor Vehicle Accidents
Motor Vehicle Accidents
Car Accidents
Truck Accidents
Motorcycle Accidents
Reckless Driving Accidents
Distracted Driving Accidents
Uber and Lyft Accidents
Delivery Truck Accidents
Motor Vehicle Child Injuries
Boating Accidents
Work Injuries
Work Injuries
Workers Compensation Claims
Industrial Accidents
Construction Accidents
Warehouse Accidents
Maximizing Injury Settlements
Track Record
Track Record
Motor Vehicle Cases
Other Injury Cases
Blog
Contact Us
MVA Intake Form Minor
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MVA Intake Form Minor
MINOR
Motor Vehicle Collision Information
Guardian’s Full Legal Name:
*
Child’s Full Legal Name:
*
Date of Collision
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
Child’s Social Security Number:
*
Health Insurance
Medicare
Medicaid
Military Insurance
None
Name of Health Insurance
Policy No:
Group No:
Guardian’s Email:
*
Guardian’s Cell Phone:
Address
Street Address
Address Line 2
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Vermont
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Washington
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact
Phone No
Your Auto Insurance
*
79055