Question 1
1
How were you hurt?
This question is required.
*
Automobile Accident
Pedestrian or Bicycle Accident
Truck Accident
Motorcycle Accident
Accident or Injury at Work
Other Injury or Accident
Question 2
2
How long ago was the accident?
This question is required.
*
More than 1 year ago
In the last 14 days
Within 3 - 6 months
More than 2 years ago
Within 1 - 3 months
Within 6 - 12 months