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?

Is the vehicle insured?

Yes

No

Please describe how the accident happened.

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

Were any citations issued or arrests made?

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

Were you injured in the accident?

Yes

No

Were you taken to the hospital?

What medical treatment have you received?

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:

Copyright ©2009 FindLaw, a Thomson Business

DISCLAIMER: This site and any information contained herein are intended for informational purposes only and should not be construed as legal advice. Seek competent legal counsel for advice on any legal matter.