Accident Information - Car Insurance

Accident Information Form

Please provide as much details as possible about the accident
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?

	1	2	3	4	5

1 is Not bad., 5 is 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.
What is level of Damage?
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Accident Information Form