Name

Address

City

State

Zip

Phone

Other Phone

Email

Name, Address, Phone and email address of injured
party if different from above:

Date of Incident/Accident

Location of Incident/Accident

Visually looking at the car, how much damage was there to the
vehicle you were in?
Minor      Moderate      Significant

Do you have a property damage estimate?
Yes      No

If you do have a property damage estimate for your car, what is the estimate value?

Visually looking at the car, how much damage was there to the other vehicle?
Minor      Moderate      Significant

What is the make, year and model of the other party's vehicle?

Did the Police/CHP prepare a report of the incident?
Yes      No

If yes to above, do you have a copy of the report?
Yes      No

What is the name of your automobile insurance company?

What is the name of the automobile insurance company for the responsible party?

Did you leave the scene by ambulance?
Yes      No

Were you seen in an Emergency Room?
Yes      No

Please describe your injuries

Please list the names of doctors you have seen regarding this incident

Do you have health insurance?
Yes      No

Do you have medical payments coverage on your own automobile policy or from the vehicle you were in at the time of the incident (if other than your own vehicle)?
Yes      No

Did you miss time from work?
Yes      No

If yes to the above, how much time did you miss from work?

How were you referred to this office?

If we meet, we ask that you bring with you the following:
1. Police Report;
2. Photos of property damage and of injuries;
3. Automobile insurance Declarations page for the car you were in at the time of the incident;
4. Your own Automobile insurance Declarations page if you were not in your own vehicle;
5. Any correspondence, claim numbers and phone numbers arising from the accident;
6. Any time off from work slips.

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