Auto Accident Form
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Gender
*
Male
Female
D.O.B
*
-
Month
-
Day
Year
Date
Your Social Security #
*
No Fault Insurance Information
Your Claim #
*
Date of Accident
*
-
Month
-
Day
Year
Date
Insurance Company
*
Policy #
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Adjustor
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Was the accident in New York State?
*
Yes
No
Please explain how your accident happened:
*
Please answer the following questions
Were you the...
*
Driver
Passenger
Were you in the...
*
Front seat
Back seat
Were you wearing a seat belt?
*
Yes
No
Were you struck from...
*
Behind
Head on
Side impact
When and where did you feel any pain?
*
Did you go to the hospital?
*
Yes
No
What treatment did you receive?
*
Did you have any x-rays or MRI taken?
*
Yes
No
If yes, where?
*
Are your work activities restricted as a result of this accident?
*
Yes
No
Since this injury, are your symptoms:
*
Getting worse
Getting Better
Staying the same
On a scale of 1-10 with 10 being the worst, how do you rate your pain today?
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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