Motor Vehicle and Accidents Contact Form
 

Motor Vehicle and Accidents Contact Form

Name:

Address:

City:

State:

Zip:

Email Address:

Phone Number:

When and where did the accident occur?

What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?

Where were you in the vehicle? Were you driving?

Who owns the vehicle involved in the accident?

Please describe how the accident happened

Were any citations issued or arrests made?

Do you believe that alcohol was a factor in causing the accident?

Were you taken to the hospital?

What medical treatment have you received?

Is the vehicle insured?

 Yes No

Were you injured in the accident?

 Yes No

Did the police come to the scene of the accident?

 Yes No

If so, do you have a copy of the police report?

 Yes No

Are you currently receiving medical treatment?

 Yes No

Was the other driver injured?

 Yes No

Were any passengers injured?

 Yes No

Please list any other concerns