Questionnaire

Seidel Subrogation Associates,L.L.C.

info@seidelsubrogationassociates.com

Questionnaire

BEFORE YOU BEGIN: Please enter the FILE NUMBER you will find on our letter to you.
Please enter your full name.
– – Please enter your phone number.

1.	Yes No	Have you or your covered dependents been involved in an accident or injured at work? If no, please stop here and submit the form so that we can update our files.

2.	Accident Date:	/ / (mm/dd/yyyy)

3a.	Yes No	Was this accident work-related?

3b.	Yes No	If so, did the work injury/illness require medical care?

3c.	If 3b is YES:	Please provide the following information as well as pertinent attorney and/or insurance information as requested in questions 7 & 8.
		Patient First Name:
		Middle Initial:
		Last Name:
		Patient Employer:
		Employer Address:
		Employer City/State/Zip:
		Injury/Illness Date:	/ / (mm/dd/yyyy)
		Injury/Illness Type:

4.	Yes No	Was this a Motor Vehicle Accident?
	If 4 is NO:	Please Describe:

5a.	Yes No	Did the accident involve another party?

5b.	Yes No	Are you covered by Personal Injury Protection?
	If 5b is YES	PIP Carrier Name:
		PIP Carrier Address:
		PIP Carrier City/State/Zip:
		PIP Carrier Phone:	– –
		Accident Location City/State/Zip:
		Claim Number:
		Adjuster's Name:

6.	Yes No	Was another person or party responsible for causing your injuries? If YES, please complete items 7, 8 and 9.

7.	Attorney Information (if applicable) Please complete if 3b is YES or 6 is YES.
		Attorney Name:
		Attorney Address:
		Attorney City/State/Zip:
		Attorney Phone:	– –

8.	Responsible person/party Insurance Company Information (if applicable) Please complete if 3b is YES or 6 is YES.
		Company Name:
		Company Address:
		Company City/State/Zip:
		Company Phone:	– –
		Claim Number:
		Adjuster's Name:

9.	Yes No	Has this case settled? Please complete if 6 is YES.
	If 9 is YES	/ / Settlement Date (mm/dd/yyyy)

10.	Additional Comments:

	To the best of my knowledge, the information on this form is true and accurate.