Auto Injury Information
Type of Accident *
Were you x-rayed at the hospital?
Were you admitted to the hospital?
Have you lost any time from work because of this accident? *
Have you returned to work since the accident? *
Were you wearing a seat belt? *
If auto accident, were you the...? *
If passenger, were you sitting in the...? *
Did your vehicle hit other vehicle(s)? *
Was your vehicle hit by another vehicle(s)? *
Did your car strike the other(s) involved? *
Did the other car strike yours? *

Vehicle You Were In

Address *
Address
City
State/Province
Zip/Postal
Insurance Co. Address *
Insurance Co. Address
City
State/Province
Zip/Postal

Other Vehicle

Address *
Address
City
State/Province
Zip/Postal
Insurance Co. Address *
Insurance Co. Address
City
State/Province
Zip/Postal
Did you require post-accident hospitalization? *
Check the symptoms you have noticed since the accident. *
Have you lost days of work? *
Have you been contacted by an Insurance Adjuster or Company Representative regarding this claim? *
Do you have an attorney who has advised you in this case? *
Address of Attorney
Address of Attorney
City
State/Province
Zip/Postal