Law Offices of Morgan D. King CONFIDENTIAL ACCIDENT INFORMATION FORM PLEASE FILL OUT THE BELOW FORM AS BEST YOU CAN. WHEN YOU CLICK THE "SUBMIT" BUTTON AT THE BOTTOM IT WILL BE SENT TO MORGAN KING BY EMAIL 1. DATE OF ACCIDENT: 2. YOUR NAME: 3. HOME PHONE NO. 4. WORK PHONE NO. 5. CELL PHONE NO. 6. EMAIL ADDRESS: 7. YOUR DATE OF BIRTH: 8. YOUR CURRENT CITY AND STATE OF RESIDENCE: 9. CITY AND STATE WHERE ACCIDENT HAPPENED: 10. TYPE OF ACCCIDENT: MOTOR VEHICLE UNSAFE PRODUCT UNSAFE PREMISES FOOD POISONING OTHER ASSAULT & BATTERY GUNSHOT ANIMAL UNSAFE SUPERVISION 11. WERE YOU MARRIED AT TIME OF ACCIDENT? YES & LIVING TOGETHER YES BUT SEPARATED NO 12. IF MOTOR VEHICLE WHAT KIND OF VEHICLES INVOLVED? NOT APPLICABLE BIG RIG OTHER TRUCK OR SUV CARS MOTORCYCLE PEDESTRIAN BICYCLE TRAILER BOAT AIRPLANE OTHER 13. BRIEFLY DESCRIBE HOW ACCIDENT HAPPENED: 14. WAS YOUR VEHICLE INSURED AT TIME OF ACCIDENT: YES NO UNK. NOT APPLICABLE 15. WERE YOU INJURED? YES NO 16. IF INJURED BRIEFLY DESCRIBE YOUR INJURIES: 17. DID YOU SPEND OVERNIGHT AT HOSPITAL BECAUSE OF YOUR INJURIES? YES NO 18. ARE YOU STILL EXPERIENCING PAIN? YES NO NOT APPLICABLE 19. ARE YOU STILL BEING TREATED? YES NO NOT APPLICABLE 20. WHAT KIND OF TREATMENT DID YOU NEED? SURGERY MEDICINE THERAPY OTHER 21. WAS AN ACCIDENT REPORT DONE BY LAW ENFORCEMENT? YES NO UNK. NOT APPLICABLE 22. WHO DOES REPORT SAY WAS AT FAULT? OTHER DRIVER ME BOTH OF US OTHER PERSON OR ENTITY UNK. NOT APPLICABLE 23. WERE PHOTOGRAPHS TAKEN OF ACCIDENT SCENE? YES NO UNK. NOT APPLICABLE 24. WERE PHOTOGRAPHS TAKEN OF YOUR INJURIES? YES NO UNK. NOT APPLICABLE 25. OTHER MEMBER(S) OF YOUR FAMILY WHO WERE INJURED: CHILD OR CHILDREN UNDER 18 ADULT CHILD OR CHILDREN SPOUSE OTHER RELATIVE NONE 26. WERE X-RAYS TAKEN OF YOUR INJURIES? YES NO UNK. NOT APPLICABLE 27. WAS YOUR VEHICLE INSURED AT TIME OF ACCIDENT? YES NO UNK. NOT APPLICABLE 28. WAS THE OTHER DRIVER OR RESPONSIBLE PARTY INSURED? YES NO UNK. NOT APPLICABLE 29. HAVE YOU LOST INCOME DUE TO YOUR INJURIES? YES NO MAYBE NOT APPLICABLE 30. HAVE YOU BEEN CONTACTED BY OTHER PARTY'S INSURANCE AGENT? YES NO UNK. NOT APPLICABLE 31. NAME OF OTHER PARTY'S INS. AGENT: 32. OTHER PARTY'S INS. AGENT PHONE NUMBER: 33. HOW DID YOU FIND OUT ABOUT ME? REFERRED BY AN EX-CLIENT OF MR. KING REFERRED BY ANOTHER ATTORNEY REFERRED BY ANOTHER PROFESSIONAL INTERNET SEARCH WORD OF MOUTH KNOW MR. KING PERSONALLY OTHER SOURCE 34. IF OTHER PARTY WAS A VEHICLE WAS IT A BUSINESS VEHICLE? YES NO UNK. NOT APPLICABLE 35. NAME OF OTHER PARTY BUSINESS (IF APPLICABLE) 36. HAVE YOU FILED A LAWSUIT IN THIS CASE? YES NO NOT APPLICABLE 37. WAS THE OTHER PARTY A PUBLIC ENTITY OR OWNED BY A PUBLIC ENTITY? YES NO UNK. NOT APPLICABLE 38. IF ACCIDENT REPORT WAS DONE WHICH ENTITY PREPARED IT? CITY POLICE COUNTY HIGHWAY PATROL PRIVATE SECURITY OTHER NOT APPLICABLE