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AUTOMOBILE ACCIDENT CONTACT FORM

** = Required Information
** Your Name:
Home Address:
City: State:
Zip:
** Home Phone:
Cell Phone:
Work Phone:
E-mail:
Date of Accident:
Do you have Automobile Insurance?

Your Policy Number:
Claim Number:
Phone Number:
Address:
Does your automobile Insurance policy have the following coverage?
Personal Injury Protection (PIP):
Underinsured/Uninsured Motorist Coverage:
Collision:
List your Prior Accidents by approximate date:
Have you ever been injured before to the extent that it required medical attention?


Please list the approximate dates and injuries:
Do you have health insurance?


Name of Health Insurance Company:


Phone:
Policy Number:
Have you missed any work due to this accident?

Have you lost any wages?
Employer:
Other Driver's Name:
     Address:
     Phone Number:
     Type of Vehicle:
Other Driver’s Insurance Information
     Name of Other Driver’s Automobile Insurance Company:



     Adjuster:
     Claim Number:
     Phone Number:
     Address:
PLEASE DESCRIBE HOW THE ACCIDENT HAPPENED:
Did you take an ambulance to the Emergency Room?

Which hospital did you visit?
Have you followed up with a treating physician?

Do you need to be referred to a physician?

Please describe your injuries:
Did the Police make an Accident Report?

Do you have any witnesses?
Approximately how much property damage was done to your vehicle?


Has your vehicle been repaired or totaled?

Do you have any Photo of your vehicle, the other vehicle or your injuries?