Motor Vehicle Accidents Contact Form

Name

Email Address

Phone Number

When and where did the accident occur?

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

Where were you sitting in the vehicle? Were you driving?

Who owns the vehicle? Is it insured?

Describe how the accident happened.

Did the police come to the scene of the accident?
Yes??No?

Were any citations issued or arrests made? In your opinion was alcohol a factor in causing the accident?

Was either driver found to be at fault for a hazardous action? Do you have a copy of the police report?

Were you injured in the accident?
Yes??No?

Were you taken to the hospital? How were you taken to the hospital?

What medical treatment have you received? Are you currently receiving medical treatment?

Were you insured on the day of the accident? Was the driver of the other vehicle(s) insured?

Are you currently under a physicians care for the injuries sustained in the accident?