Gary G. Goldberg - Get the extra attention you deserve

	ggg@calinjuryattorney.com 3673 Arlington Ave. Riverside, CA 92506 (951) 788-8325

Questionnaire

Today's Date:
Name:
E-Mail Address:
Home Phone: Work Phone:
Address:
City: State:
Date of Accident:
Time of Accident:
Police Report:
City/State where accident occurred:
Were you the:
Number of passengers: Were any passengers injured:
How accident occurred:
Name of your auto insurance on date of accident:

Type of coverage (select all that apply):

	Full Coverage
	Uninsured Motorist
	Medical Payments Coverage
	Liability Only
	Comprehensive/Collision

Name of insurance company of party at fault:
What are your injuries:
Have you seen a doctor yet?:
If Yes, please list all names of doctors and facilities where you were treated:

What is the Year, Make and Model of your vehicle:

Did you get a repair estimate yet?:
If Yes, estimate amount:
Has your vehicle been repaired?:
If Yes, how much did it cost to repair?:
What is the Year, Make, and Model of the other vehicle:

Did the other vehicle sustain damages?:
Did you get the name(s) and address(es) of any witness(es)?