Plaintiff name: _________________________________

address: _________________________________

phone home: _________________________________

d/o/b: _________________________________

Soc.. security: _________________________________

Spouse _________________________________

2a. Date of Accident: _________________________________

town, county, state: _________________________________

day of week _________________________________

time: _________________________________

weather _________________________________

Road conditions _________________________________

2b. Operator of Plaintiff's car: _________________________________

Owner of Plaintiff's car: _________________________________ _________________________________

2c Other occupant's of Plaintiff's car. _________________________________

2d Street Plaintiff was traveling on: _______________________

Direction of travel (ex- North, south, etc.): _________________________________ _________________________________

Nearest approaching road: _________________________________

2e Street Defendant was traveling on: _________________________

Defendant Direction of travel (ex- North, south, etc.): _________________________________ _________________________________

Nearest approaching road: _________________________________

2f Traffic lights or stop signs in area: __________________________

2g Description of Accident: _________________________________

3. INJURIES- NATURE, EXTENT, DURATION

4. PERMANENT INJURIES AND PRESENT COMPLAINTS

5. HOSPITALS- ADDRESS, DATE OF ADMISSION DISCHARGE

6- X-RAYS, TAKEN BY: _________________________________

ADDRESS _________________________________

DIAGNOSTIC TESTS: _________________________________ _________________________________

X-ray, MRI DATE _________________________________

RESULTS _________________________________

7 DOCTOR-NAME _________________________________

ADDRESS PHONE DATES OF TREATMENT: _________________________________

DATE OF REPORTS: _________________________________

7B. MEDICAL PROVIDER-NAME __________________________

ADDRESS PHONE DATES OF TREATMENT: _________________________________

DATE OF REPORTS: _________________________________

7C MEDICAL PROVIDER-NAME ADDRESS PHONE DATES OF TREATMENT: _________________________________

DATE OF REPORTS: _________________________________

8. STILL BEING TREATED? MEDICAL PROVIDER-NAME NATURE OF TREATMENT AND NATURE OF TREATMENT

9. AGGRAVATION OF PRIOR INJURIES BY ACCIDENT, PRIOR DOCTOR

10. Employer Name: _________________________________ Address: _________________________________ Job/Position Gross/week Net/week Time Lost Total Wages Lost: _________________________________

11. IF RETURN TO WORK: _________________________________ Current Employer Name: _________________________________ Address: _________________________________ Job: _________________________________ ________________________ Gross/week Net/week

12- OTHER LOSS OF INCOME, EARNINGS

13. Medical bills, Doctor Amount unpaid Paid hospital bills, medicine, etc. Total medicals (As of ________): _________________________________

14. OTHER OUT OF POCKET EXPENSES and OTHER LOSSES

15. Relevant Documents: _________________________________ _________________________________ Identify all documents that may relate to this action, and attach copies of each such document, such as police report, hospital bills, etc. Police Report: _________________________________ _____________________________________________ Declaration Sheet: _________________________________ _________________________________ ____________ Hospital Bills: _________________________________ _________________________________ ____________ Hospital Records: _________________________________ _________________________________ ____________ Medical Bills and Records ____________ Photographs of Accident Site: _________________________________ _________________________________ ____________ Photographs of Damage to Plaintiff's car: _________________________________ _________________________________ ____________ Photographs of Damage to Defendant's car: _________________________________ _________________________________ ____________ Photographs of Injuries, scars, cuts: _________________________________ _________________________________ ____________ Repair damage estimate: _________________________________ _________________________________ ____________

Other: _________________________________ _________________________________ __________

16a defendant name: _________________________________ _________________________________ address: _________________________________ _________________________________ Owner of Def car: _________________________________ address: _________________________________ Type of car: _________________________________ ___________________________ make, year Other occupants of def car

16b Eye witness name: _________________________________ address & phone: _________________________________

17 Names and addresses of People with Relevant Knowledge

Officers of Investigating Police Department: _________________________________

18. Photographs: _________________________________ _________________________________ If any photographs, videotapes, audio tapes or other forms of electronic recordings, sketches, reproductions, charts or maps were made with respect to anything that is relevant to the subject matter of the complaint, describe: _________________________________ _________________________________ (a) the number of each; (b) what each shows or contains; (c) the date taken or made; (d) the names and addresses of the persons who made them; (e) in whose possession they are at present; and (f) if in your possession, attach a copy, or if not subject to convenient copying, state the location where inspection and copying may take place. ___________

19. If you claim that the defendant made any admissions as to the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date made; (b) the name of the person by whom made; (c) the name and address of the person to whom made; (d) where made; (e) the name and address of each person present at the time the admission was made; (f) the contents of the admission; and (g) if in writing, attach a copy.

20. If you or your representative and the defendant have had any oral communication concerning the subject matter of this lawsuit, state: _________________________________ _________________________________ (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication.

21. If you have obtained a statement from any person not a party to this action, state: _________________________________ _________________________________ (a) the name and present address of the person who gave the statement; (b) whether the statement was oral or in writing and if in writing, attach a copy; (c) the date statement was obtained; (d) if such statement was oral, whether a recording was made, and if so, the nature of the recording and the name and present address of the person who has custody of it; (e) if the statement was written, whether it was signed by the person making it; (f) the name and address of the person who obtained the statement; and (g) if the statement was oral, a detailed summary of its contents. _____________________________

22: _________________________________ ___________________________ Violation by Defendant of Motor Vehicle law (i.e. Careless driving or other statute

23. Expert witnesses: _________________________________ 24. Have you every been indicted and convicted of a crime? ______ (This question required by Rules of Court)

25a Plaintiff car ins company: _________________________________ THRESHOLD address: _________________________________ phone: _________________________________ policy # claim # year, make, model collision coverage Who Notified? UM/ UIM coverage

25b Named Insured: _________________________________ _________________________________ _____________________________________

25c Copy of Dec Sheet: _________________________________

25d. Plaintiff's private major- medical ex- Blue Cross address: _________________________________ phone: _________________________________ Policy number

26a: Distance between Plaintiff and point of impact when first observed other vehicle and Plaintiff's speed: _________________________________

26b: distance between Plaintiff and the Defendant's vehicle when first observed other vehicle: _________________________________ ___________________________________________________________

26c: Where Plaintiff's vehicle came to rest and where Defendant's vehicle came to rest: _____________________________ ___________________________________________________________

27: Part of Plaintiff's car hit by Defendant's car: _________________________________ ________________________________________________________

Damage to Plaintiff's car: _________________________________ _________________________________ _______________________________________

Property damage estimate: _________________ ___________________________________________________________

28: Where Plaintiff was coming from and where Plaintiff was going to: _________________________________ ___________________________________________________________

29. Parts of body hitting car: _________________________________ _________________________________ _____________________

30. Unconsciousness? _____________________

31. Skid marks by any car: _________________________________ _________________________________ _____________________

32. Defendant's Ins carrier 33. address: _________________________________ phone: _________________________________ 34. adjuster: _________________________________ 35. Policy limits: _________________________________ claim #: _________________________________

36. When did you apply your brakes?: ___________________________ _________________________________ _____________________

37. How fast were you going?: _________________________________ _________________________________ _____________________

38. How fast was the Defendant going?: _________________________________ _________________________________ _____________________

39. Describe the position of each car at the point of impact, giving distance from curb, lines, streets or other landmarks?: _________________________________ _________________________________ _____________________

40. Alcoholic beverages or medication within 12 hours before accident? _______

41. Prior accidents involving injury in which you received an insurance settlement or suit was started? (Including worker's compensation)? Prior car accidents with only property damage? _____________________

42. Negligent actions by Defendant: _________________________________ _________________________________

43. What else did you tell police? _____________________

44. Set forth the names of insurance agents and other individuals you discussed the case with an what did you say? _____________________

45. Please prepare a Diagram of the accident site _____________________

46. Are you receiving Medicare/ Medicaid? ___________ Are you receiving SSI? ___________

Is there anything else important? ___________________________

___________________________________________________________ ___________________________________________________________