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MVA Intake Form Minor

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 City State ZIP Code
Emergency Contact
Phone No
Your Auto Insurance*