Car Insurance-Accident Information Form

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.
Should be Empty: