Accidental Injury Form

Name

Date

Date of Accident

Time including AM/PM

Location of Accident

Auto Injury

Were You:

Driver Passenger Pedestrian

Were you struck from:

Behind Right Side Left Side Front Parked

Did your car strike the others involved:

Yes No Undetermined

Did the other car strike yours:

Yes No Undetermined

As a result of the Accident, were traffic citations issued to you?

Yes No

Who was at Fault

Myself Other Party Not Assigned

Explain what happened in your own words:

On-the-job Injury

How did the injury occur?

Did you report the injury to your foreman or employer?

Yes No

Describe the circumstances of the accident (Be Specific)

Employer

Address

Check symptoms you have had since the accident

Did you require post-accident hospitalization?

Yes No

Have you lost any days of work?

Yes No

If yes, dates starting:

Ending:

Insurance Information

YOUR Insurance Company

Claim Number

Claim Adjuster Name

Claim Adjuster Phone Number

OTHER Party's Insurance

Adjusters Name

Have you been contacted by an insurance adjustor regarding this claim?

Yes No

If yes, name of adjustor

Company

Do you have an attorney that has advised you in this case?

Yes No

If yes, attorney's name

Phone Number

Signature

Please type your full name as your signature

Date Signed