Intake – RASA Houston

Name of Adjuster

Insurance Company Name

Claim No

Phone No

Fax

Email

Personal Injury Intake Summary
Pesiones personales-un resumen breve en tomas

Person Completing in take

Today's Date

Date of Incident

Time

Place

Nature of Liability

Client Name on ID

Telephone Number

TDL

DOB

SS NO

Martial Status

Emergency Contact

Address

Email

How many people in your vehicle:

Are you the driver or passenger?

Era usted el conductor o pasajero

Driver Passenger

Did you go to the emergency room?

¿Fue al cuarto de emergencia?

Yes No

Name of ER:

Your Injuries

Have you missed time from work?

What do you do for a living?

Are you eligible for Medicaid/Medicare?

Do you have health insurance?

How the accident occur, where were you going/ coming (Be as specific)

Police agency that came to the scene

Crash report no

Reffered By

Previous accidents?

Adverse Driver’s Insurance Company Name

Policy No

Name of Adverse Driver (At fault Driver):

DOB

Types of Vehicle

Make, Model, Color

Your Insurance Information, Insurance Company Name?

Your Policy

Claim

Adjuster Name

Phone No

Your Coverage
Su numero de póliza

Property Damage

Cantidad de estimado/pagado ponga circulo

Estimate Paid Amount

Type & Make of your vehicle

Plate

Color

Vehicle Driva-able?

Towed to

Do you have scene and vehicle pictures?

Lienholder Account number

Phone Number

Address

Who is title under?

Upload Files

Please send me the pictures of your police case number/citizen exchange form, for your auto accident, insurance and any documents you have for the other person/s, a picture of your driver’s license, pictures of your car and the vehicle/s involved, accident scene picture, your insurance

Notes:

Personal Injury Intake SummaryPesiones personales-un resumen breve en tomas

Are you the driver or passenger?

Did you go to the emergency room?

Your Coverage Su numero de póliza

Personal Injury Intake Summary
Pesiones personales-un resumen breve en tomas

Your Coverage
Su numero de póliza