What information do I need to obtain at the accident scene if I am involved in an automobile accident?
VEHICLE PLAINTIFF WAS DRIVING OR PASSENGER IN
Vehicle Make:
Vehicle Model/Yr:
Color
Damage to vehicle: Amt and location,visual damage, scratches etc
Drivable
Location of vehicle: address and tel#
Vehicle towed by :
Driver Name
Address
Telephone #
Bus # :
Drivers Licence #
Owner
Address
Telephone #
Tag No.:
PIP Insurance Company:
PIP Amount:
Policy
Claim No.:
PIP Adjuster:
PIP Adjuster’s phone number:
PIP Adjuster’s fax number:
PIP Adjustor address:
Liability Adjustor for host vehicle
Liability Adjuster:
Liability Adjuster’s phone number:
Liability Adjuster’s fax number:
Liability Adjustor address:
Household pip coverage
Insurance Co
Policy #
Claim#
Adjuster
Waived? Yes or no
Relationship to client
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
EMPLOYMENT
Employer #1:
Phone:
Address:
Occupation:
Average Wage:
Dates of Employment:
Dates missed from work:
Employer #2:
Phone:
Address:
Occupation:
Average Wage:
Dates of Employment:
Dates missed from work:
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
Police Dept?:
Report Number:
Police Officer name
Tel#
Address
Passengers: Yes ( ) No ( )
- Name
Address
Tel#
- Name
Address
Tel#
- Name
Address
Tel#
- Name
Address
Tel#
Witnesses Yes ( ) No ( )
- Name
Address
Tel phone#
Version
- Name
Address
Tel phone#
Version
- Name
Address
Tel phone#
Version
Seat belt?: Air bags?:
RESPONSIBLE PARTY
DRIVER Name:
Address:
Phone number:
Tag #: :
DRIVERS License No.:
Speak with person, what did they say:
Year
Make
Model:
Color
Damage
drivable
Insurance Co.:
PolicyNo.:
Agent name and tel #
Claim #:
Adjustor name
Tel#
Fax#
Address
Owner’s name:
Owner’s phone number:
Owner Address
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
DAMAGES
Injuries:
Prior Injuries to same body parts:
Prior MVA’s:
PRIOR WCC
Primary Care Dr:
Hospital:
When:
Ambulance?:
Doctors
- Name
Address
Telephone #
- Name
Address
Telephone #
- Name
Address
Telephone #
Health Insurance Info
Name of company
Policy#
Insured name
Medicare
Medicare number
Regular medicare or special plan
Medigap Ins co
Policy #
Prescription Plan-name and policy#
Medicaid
Name of company
Policy #
Veterans Insurance
Location of Va treatment
FACTS OF ACCIDENT: Need direction of vehicles,One way or two way, Lanes each way,
Any admission of fault by other vehicle at scene