PERSONAL INFORMATION

Social Security #

Driver's License

Spouse's full name, if married

Military Service?

Yes

Dates of Service Branch of Military Any Military-Service Related Injuries

No

ACCIDENT INFORMATION

Is this an auto accident?

Yes

No

What type of accident?

Driver or Passenger?

Date of incident

Time of Incident: AM or PM?

City of incident

County of incident

Road/Intersection (if applicable)

Were the police called to the scene?

Yes

No

Was an accident or incident report filed?

Yes

What is the police report or accident report #? Attach report, if available.

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No

Describe how the incident occurred

Photo / Diagram upload

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OTHER PARTY If KNOWN/ APPLICABLE

Name of the other party

Address

Phone number

His / Her job

His / Her age

Did he/she have insurance?

Yes

Identify his/her insurance company His/her policy number? His/her insurance adjuster? His / Her insurance coverage

No

Did he/she have insurance?

Yes

His/her insurance company His/her policy number? His/her insurance adjuster? His / Her insurance coverage

No

Do you know what the other party’s financial circumstances are without regard to any insurance he/she may have?

Yes

If so, please specify:

No

Give your observations about the party as a person

How did the defendant’s car leave the scene? If towed, state by whom and where taken?

AUTOMOBILE INFORMATION

What is the make, model, and year of your car?

Who was the operator of your car?

What is the license plate number of your car?

What was the damage to your car?

Did you have to rent a car?

Yes

If so, give the name of the company and the amount of the rental?

No

What is the make, model, and year of the other party’s car?

Who was the Operator of that car?

What was the license plate number of that car?

What was the damage to that car?

Who investigated the accident?

Police

State Patrol

Sheriff

No Investigation

Describe the point of impact for each auto

How far did the cars travel after impact?

Position of vehicles after impact

How did you leave the scene of the accident?

PASSENGERS

Passenger #1: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Seated Injuries

No

Passenger #2: if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Seated Injuries

No

Passenger #3: if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Seated Injuries

No

Passenger #4: if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Seated Injuries

No

Passenger #5: if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Seated Injuries

No

Additional Details:

WITNESSES

Witness #1: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Telephone What witness knows

No

Witness #2: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Telephone What witness knows

No

Witness #3: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Telephone What witness knows

No

Witness #4: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Telephone What witness knows

No

Witness #5: (if applicable, please select "Yes" and fill out the following information)

Yes

Name Address Age Telephone What witness knows

No

Additional Details:

STATEMENTS MADE

Name of your auto insurance carrier

Name of policy holder

Policy number

Agent / adjuster

Telephone number

Claim number (if known)

Type of coverage

Personal Injury Plan (PIP) limits

INJURIES

Check symptoms you have noticed since the accident

Headache

Neck pain

Hands cold

Loss of balance

Depression

Pins & needles in arms

Nervousness

Numbness in toes

Chest pain

Neck stiff

Stomach upset

Fainting

Lights bother eyes

Pins & needles in legs

Ears ringing

Shortness of breath

Dizziness

Sleeping problem

Back pain

Loss of smell

Loss of memory

Feet cold

Buzzing in ears

Fatigue

Head seems too heavy

Numbness in fingers

Cold sweats

Tension

Muscle Pain

Other Numbess

Did you go to the hospital?

Yes

Name of the hospital?

No

Did you go by ambulance?

Yes

Name of ambulance service:

No

Did they take x-rays?

Yes

No

Have you seen a doctor since the date of the accident, other than at the emergency room?

Yes

If yes, please list all Doctors: name, address and telephone number

No

INJURY HISTORY

Injury #1 (if applicable, please select "Yes" and fill out the following information)

Yes

Date Place Nature of Accident Injury Treated By

No

Injury #2 (if applicable, please select "Yes" and fill out the following information)

Yes

Date Place Nature of Accident Injury Treated By

No

Injury #3 (if applicable, please select "Yes" and fill out the following information)

Yes

Date Place Nature of Accident Injury Treated By

No

Injury #4 (if applicable, please select "Yes" and fill out the following information)

Yes

Date Place Nature of Accident Injury Treated By

No

LOSS OF EARNINGS

Employer

Your position or title

Rate of pay: $ ____ per hour

Rate of pay: $____ yearly salary

How many hours do you normally work per week?

ADDITIONAL INFORMATION

Any additional Information you think would be helpful

THANK YOU