accident inquiry form

First Name
Last Name
Street Address
City, State, Zip
Home Phone
Work Phone
Email Address
What is the best way to reach you?
Are you seeking information for yourself or someone else?
Is an attorney currently representing you in this matter? Yes No
How did you hear about us?
   
Accident Information:  
Type of accident
If Other, please specify
Date of accident
Time of accident
Location of accident (include city, state and specific street names, if possible)
What caused the accident?
Did injuries result to you, your passengers, or the other driver and passengers as a result of the accident? Yes No
If you have injuries, do they prevent you from working? Yes No
If yes:  
When did you stop working?
How much income have you lost as a result of the accident and your injuries?
What are your medical expenses to date?
Is there damage to your vehicle or the other driver’s vehicle? Yes No
If yes:  
What is the approximate damage to your vehicle?
Are you renting a vehicle and, if so, what is the cost?
What is the approximate damage to the other driver’s vehicle?
Do you have a copy of the police report? Yes No
Name of your auto insurance company
Name of the other driver’s auto insurance company
Any other information you feel is valuable to your case