McKinley Law - MOTOR VEHICLE ACCIDENT INJURY CLAIM FORM

MOTOR VEHICLE ACCIDENT INJURY CLAIM FORM

Part 1: YOUR DETAILS
Full name:
Address:
Email:
Telephone:
Date of birth:
Occupation:

Part 2: PARTICULARS OF ACCIDENT
Approx. date / time:
Location: (street names/suburb)
Were you: (select which applies)	Driver of vehicle Passenger Pedestrian
General description of the accident:
Was the accident reported to the police?	Yes No

Part 3: DETAILS OF INJURIES
What injuries did you sustain in the accident?
Were you hospitalised following the accident?	Yes No
If not, did you consult your medical practitioner following the accident?	Yes No
Please provide details of treatment administered:

Part 4: DISABILITIES AND EFFECTS OF THE ACCIDENT
How have your injuries affected you?

Part 5: LOSS OF EARNINGS/EARNING CAPACITY
Are you:	employed full time employed part time/casual self employed retiree/pensioner unemployment/sickness benefits
If applicable, period of absence from work due to injury:
Are you receiving Social Security/Centrelink benefits as a direct result of this accident?	Yes No