Make sure you’ve covered all the bases and gotten all the information your attorney and insurance company will need to process your claim and assess the accident by checking out this run-down of questions to know. Click here to see a sample accident report sheet.Information includes:
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
 
 
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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:
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Police Dept?:
Report Number:
Police Officer name
Tel#
Address
Passengers:  Yes (  )    No  (  )

1. Name

Address
Tel#

1. Name

Address
Tel#

1. Name

Address
Tel#

1. Name

Address
Tel#
Witnesses   Yes (  )    No  (  )

1. Name

Address
Tel phone#
Version

1. Name

Address
Tel phone#
Version

1. 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
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DAMAGES
Injuries:
Prior Injuries to same body parts:
Prior MVA’s:
PRIOR WCC
Primary Care Dr:
Hospital:
When:
Ambulance?:
Doctors

1. Name

Address
Telephone #

1. Name

Address
Telephone #

1. 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