Motor Vehicle Accident Form

Motor Vehicle Accidents

Client Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone
Email*
Date of Birth*
MM slash DD slash YYYY
SSN#
Emergency Contact
First Last
Phone
Marital Status
- Married
- Single
Spouse's Name (If applicable)
Client's Auto Insurance
Address (if known)
Street Address City State / Province / Region ZIP / Postal Code Country
Policy Number
Claim Number
Adjuster Name
First Last
Ph#
Copy of Insurance Declarations Page Attached?
Coverages's: Uninsured Motorist
Medical
Collision/Comp Coverage
Deductible
Drivers License Number
State
Year/Make/Model of Vehicle
Plate Number
State
Registered Owner
Is Vehicle Driveable?
Did airbags Deploy?
Location of Vehicle?
DEFENDANT INFO:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone #
Drivers License Number
DOB
MM slash DD slash YYYY
Insurance Carrier:
Policy #
Claim Number
Adjuster Name
First Last
Phone #
Year/Make/Model of Vehicle
Plate #
State
Registered Owner
First Last
HEALTH INSURANCE
Does Client Have Health Insurance
Does client have Government Insurance? (eg. Medicare)
Health Insurance Carrier
Phone #
Subscriber's Name
First Last
Member #
MEDICAL PROVIDERS
Was Client treated by Paramedics?
Was Client transported to Hospital via Ambulance?
Name of First Hospital/ Doctor Seen
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
X-Rays Taken?
Name of Other Doctor's Seen
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Other's Seen
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Has Client received any medical bills?
If yes, please submit
EVIDENCE
Phone
Police Report/Agency
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Report #
Vehicle Photos Received by Investigator?
Bodily Injury Photos Received by Investigator?
EMPLOYMENT INFO
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone #
Position Title
Time Missed from Work
Pay Rate
Who is the contact person to verify time missed from work?
First Last
Phone #
DETAILS OF ACCIDENT
Date of Accident
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Location (street/city)
Describe what happened
What were the weather conditions?
Were you wearing your seatbelt?
Position in Vehicle?
Where was the impact of the car?
What/where are your injuries/pain complaints?
Did you lose consciousness?
Were there any witnesses?
Have you had any previous accidents/injuries?
Anything else you would like to mention?