Motor Vehicle Accident Information

Elements Holistic Wellness
Motor Vehicle Accident Information Form
Full Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Accident

MonthDayYear
State Accident Took Place In
Name of Insured

First NameLast Name
Insurance Company
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Adjuster's Name

First NameLast Name
Adjuster's Phone Number

Area CodePhone Number
Adjuster's Extension
Adjuster's Fax Number

Area CodePhone Number
Policy Number
Claim Number
Attorney's Name
Attorney's Phone Number
How many cars were involved?
Who was at fault?
Please describe the accident.
What are your current symptoms from the accident?
What is your pain level?
O - Not bad. 5 - Unbearable.
Are you currently under the care of a physician for the injuries listed above?
Are you currently taking any medications for your injuries?
If your answer to the above question is yes, please list your medications.
Did you have any previous injuries/ailments prior to your current MVA?
If your answer to the above question is yes, please list your previous problems, with dates.
Please Read Carefully:

By electronically signing this form, I understand my primary auto insurance will be billed for any and all services and treatments provided by Elements Holistic Wellness. I am aware that I am personally responsible for charges incurred if primary or secondary insurance refuses to pay. I also understand that is there is a balance left at the time of settlement that my medical/treatment bills will be paid for first. If I obtain an attorney, it is my responsibility to get that information to Elements Holistic Wellness as soon as possible.

*Insurance rates are "usual and customary" for the State of Oregon.
Electronic Signature: Please write our your full name and today's date.
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Elements Holistic Wellness

Motor Vehicle Accident Information Form