Grillo Intake – GRIA Systems

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MVA Form

MIC

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DOC

Document Upload - OCR Auto-Fill

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DLDriver's LicenceJPG / PNG / PDF / 10MB

HCHealth CardJPG / PNG / PDF / 10MB

INSInsurance Pink SlipJPG / PNG / PDF / 10MB

PRPolice ReportJPG / PNG / PDF / 10MB

Additional Files

Administrative

Matter ID

Date of Loss (DOL)

Date of Interview

Interviewer

Referred By

Retainer Signed

6 Month TORT Review Conflict Check on GhostPractice

Claim Type

AB Only AB and TORT TORT Only

Client Role & Position

Driver Pedestrian Cyclist E-Bike Passenger Position:

Responsible TORT Lawyer

Responsible AB Paralegal

Client Personal Information

Full Name *

Date of Birth

Address

Home #

Mobile #

Language Spoken

Interpreter Required

Interpreter Language

Marital Status

Single Married Common Law Separated Divorced Widow

# of Children

Driver's Licence No.

Class of Licence

Restrictions (lenses / medical)

O.H.I.P. #

S.I.N. #

Emergency Contact

Name

Tel Number

Relationship

Social Media

Do You Have Social Media? (Facebook, Instagram, etc.)

Can We Change Your Privacy Settings?

Is a City Entity or Province Involved? (unsafe road, black ice, improper signage, etc.)

City Entity Details

Automobile Insurance Accident Benefits

Are You Covered Under Any of the Following Automobile Insurance Policies?

Your Own Policy Yes No

Your Spouse's Policy Yes No

Policy of Any Persons You Are Dependent On (Parent) Yes No

A Policy That Lists You as a Driver Yes No

Your Employer's Policy Yes No

Policy of Any Persons in Your Household Yes No

Policy of the Vehicle You Were In Yes No

Policy of the Vehicle That Struck You Yes No

Policy of Any Other Vehicle Involved Yes No

Policy Effective Date

Expiry Date

Name of Policy Holder

Insurance Company

Submit OCF-1?

AB File Request?

Policy No.

Claim No.

Optional Benefits Purchased?

Client's Vehicle

Make

Colour

Model

Year

# of Doors

Plate No.

Owner of Vehicle

Owner Address

Accident Details

Street Location

City

Time

Police on Scene

Self-Reported

Report No.

Officer Name

Badge No.

Charges Laid?

What Charge?

Against Client?

HTA or CC Summons

Going To?

Coming From?

Road, Conditions & Weather

Road

Incline Decline Flat Straight Curved

Seat Belt

Yes No

Road Conditions

Wet Dry

Weather

Rain Snow Sunny Hot Cold Ice Dark

Windows

Up Down

Wipers On?

Yes No

View Obstructed?

Yes No

Narrative of Accident

Occupants in Vehicle

Occupant #1

Name

Phone #

Relationship

Position in Vehicle

Age

Occupant #2

Name

Phone #

Relationship

Position in Vehicle

Age

Occupant #3

Name

Phone #

Relationship

Position in Vehicle

Age

Defendant Information

(1) Name (Driver & Owner)

Name

Address

Insurance Company

Policy No.

Make

Model

Year

Colour

Plate No.

(2) Name (Driver & Owner)

Name

Address

Insurance Company

Policy No.

Make

Model

Year

Colour

Plate No.

Property Damage & Witnesses

Description & Amount of Damage to Your Vehicle

Total Loss / Write Off?

Secondary Impact?

Personal Property Damaged? (clothing, glasses, hearing aids, dentures, medical devices provide receipts)

Photographs & Evidence

Scene Photos Car Photos Injury Photos Videos / Dash Cam Footage

Witnesses to MVA

Name

Address

Phone #

Injuries, Prior Claims & Pre-Existing

Injuries (Physical, Emotional/Psychological, Dental, Social Impacts, Etc.)

Previous Claims

WSIB MVA (TORT) MVA (AB) Slip & Fall Other

Date

Open / Settled

Insurer

Previous Rep

Criminal Convictions (last 35 years)

Any Current or Past Criminal Convictions?

Details

Substance Abuse Issues (last 35 years)

Any Current or Past Substance Abuse Issues?

Details

Pre-Existing Injuries / Diagnosis

Specify cause, duration e.g. fibromyalgia, anxiety, depression, surgeries, diabetes, cancer

Employment Information

Employed

Full-Time Part-Time

Job Offer

To Start: Position: Rate:

FT PT

Homemaker

Student

Full-Time Part-Time

Self Employed

Inc. Sole Proprietor

Unemployed

Last Day Worked: Position: Reason Left: Rate of Pay:

Employment Insurance (EI)

How Long: Monthly Amount:

Caregiver

To:

Welfare (Ontario Works)

How Long: Monthly Amount:

Temporary Lay-Off

Last Day Worked: Union? Yes No Reason:

On W.S.I.B.

Plan to RTW? Yes No Date of Injury: Injuries:

Retiree

Since: Position:

ODSP

Since: Reason: Monthly Amount:

Work Impact

Do Injuries Prevent You From Working?

From What Date?

If Yes to Modified Duties

If Yes to Modified Hours

Were You Able to Return to Work?

Date Returned

Did Accident Occur While at Work?

Did You File a Claim With WSIB?

Which Period Had Your Highest Average Weekly Income?

Last 4 Weeks (not applicable for self-employed) Last 52 Weeks Last Fiscal Year (self-employed only)

Current Employer

Employer Name

Address

Phone #

Occupation / Job Title

Salary

Hours Worked

Length of Employment

Type

Full Time Part Time Seasonal ContractUnion: Yes No

Previous Employer

Employer Name

Address

Phone #

Occupation

Salary

Hours Worked

Length of Employment

Type

Full Time Part Time Seasonal ContractUnion: Yes No

Accountant Information

Name

Phone #

Medical Information

Ambulance Required?

Who Called 911?

Hospital Visit?

Hospital Name

Did Visitors Incur Expenses to Visit You? (gas, etc. provide receipts)

Diagnostic Imaging

X-RayWhere (body part) / When:

CT ScanWhere (body part) / When:

MRIWhere (body part) / When:

UltrasoundWhere (body part) / When:

Family Physician

Name

Address

Phone No.

Fax

How Long With This GP?

1st Visit to GP After MVA

Most Recent Visit

Next Scheduled Apt

Previous Family Physician / Specialist

Name

Address

Phone #

Fax

From

Walk-In Clinic

Name

Address

Phone #

Fax

Pharmacy

Name

Address

Phone #

Fax

Prescribed Medication for MVA?

Physiotherapy

Name

Address

Phone #

Fax

Start Date

Referred By

Pre-Accident Activities (home, leisure, etc.)

Service Provider, Medical Benefits, Caregiving & Student

Service Provider

Name

Address

Phone #

Relationship to Client

Occupation

Will Provider Miss Overtime / Regular Time / Vacation? (provide proof paystubs, gas receipts, employer note)

Have You Paid?

Promised to Pay?

What Amount?

Are There Receipts?

Services Being Provided

Do You Know a Family Member / Friend Who Is a PSW? Are They Able to Provide Services?

Medical Benefits

Extended Health Coverage?

Your Own Spouse

Benefits Available Under Extended Health Plan?

Short-Term or Long-Term Disability Benefits?

Name of Carrier

Policy #

Amount of Benefits

Caregiving

(1) Name

Date of Birth

Disabled?

If Yes, Details

(2) Name

Date of Birth

Disabled?

If Yes, Details

Were You Paid to Provide Care?

Student Attending School

Were You a Student at Time of Accident?

Able to Return to School After Accident?

Last Date Attended

Name / Address of School

Program

Full-Time / Part-Time

Year

Expected Date of Completion

Have You Requested Accommodation? (note taker, extended exam hours, ergonomic, extended deadlines)

Did You Complete Education Less Than 1 Year Before Accident?

Have You Incurred Educational Out-of-Pocket Expenses?

INJ

Injury Body Map

Filter by category or body region, then choose injuries from the related boxes. Auto-fills the Injuries field in Section 08.

0 selected

Injury Assessment

Identify and categorize the locations of physical or psychological trauma sustained during the incident to ensure accurate legal documentation.

Choose a category above to show the related injury boxes, then select the injuries that apply.

Body Region Shortcuts

Common MVA Sets

Use these as starting points. Staff can still add or remove any injury below.

Selected Injuries

Head / Neck

Torso / Spine

Upper Limbs

Lower Limbs

Other Physical

Consciousness / Memory

Dizziness / Balance

Sensory Changes

Neurological Red Flags

Headache

Trauma Response

Mood / Anxiety

Arousal / Behaviour

Sleep / Function

Jaw Function

Eating / Drinking

Add Unlisted Injury

Selected Injury Text

Auto-syncs to Section 08 injuries field.

No injuries selected yet

MAIL

Welcome Email

Fill the intake form first - client name auto-populates. Select legal team to generate the welcome email with correct contacts and CC list.

Client Name

Client Email *

Legal Team

Clerk Selection

Will be CC'd

Email Body

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