Automobile Claim
Name:
*
Email:
*
Phone:
Date of incident:
Where were you traveling to:
Where did it happen:
Who was in the car:
Relationship to the people in the car with you:
Insurance carrier:
Did you receive a ticket:
Yes
No
Was there a police report issued:
Yes
No
What police department issued the report:
Describe in your own words what happened:
What do you think the party at fault could have done differently to avoid the incident:
Were you taken to the hospital by ambulance:
Yes
No
If so, what ambulance service:
What hospital were you taken to:
What was their diagnosis:
If you were not taken to the hospital after the incident, where did you go for treatment:
When did you receive treatment:
What was their diagnosis:
As a result of this incident, what prescriptions have you been prescribed:
What medication are you on that is not directly related to this incident:
What is your daily dosing:
Were you sick at the time of the incident:
Yes
No
Were you under the influence of any medication at the time of the incident:
Yes
No
Were there other witnesses to the incident besides you, the driver at fault, and the passengers:
Yes
No
Do you have previous auto incidents:
Yes
No
If yes, were you at fault:
Yes
No
What injuries did you suffer from previous auto incidents:
Ever been hurt before from a non-auto incident:
Yes
No
If yes, please describe:
have you had any surgeries:
Yes
No
What kind: