Motor Vehicle Accident History Form
ADVERTISEMENT
1
2MOTOR VEHICLE ACCIDENT HISTORY
Please complete the following to help us process your accident claim as quickly as possible, Thank you!
*NAME___________________________________ *BIRTHDATE __________________________________
*DATE OF ACCIDENT____________________ TIME _______________AM/PM
LOCATION__________________________________________ CITY________________________________
*AUTO INSURANCE CO.______________________________ *POLICY #____________________________
*NAME OF INSURED (Policy Holder)________________________ *CLAIM # ________________________
*INSURANCE CLAIM ADJUSTER ___________________PHONE #______________ FAX# _____________
ADDRESS (Insurance Co.) ____________________________
_______________
__________
City/Prov.
Postal Code
Were you employed at the time of your accident?
Yes
No
* required field
Tell Us About The Accident:
What type of accident was it?
Head on
Rear end
Side impact
Other___________________
Road Conditions:
Wet
Dry
Snow/Ice
Other________________________
Driver’s seat
Passenger’s seat
Where were you seated in the vehicle?
Back seat
Were you wearing a seatbelt? Yes / No
Lap belt
Shoulder strap
What speed were you traveling? ______ km/hr What speed was the other car traveling? ______ km/hr
Was your vehicle
speeding up
slowing down at the time of the accident?
Was the other vehicle
speeding up
slowing down at the time of the accident?
Describe, to the best of your ability, what happened during the accident:
Were you prepared for the impact at the time of the collision?
Yes
No
Was your head turned at the time of the accident?
Yes
No
If yes,
Left
Right ?
Did you hit your head during the accident?
Yes
No
Did you lose consciousness?
Yes
No
If yes, for how long? _______
When did you first notice pain?
immediately
gradually ___________ hours/days after the accident?
Yes
No
Were you taken to the hospital following the accident?
Yes
No
Did you have X-rays taken?
If yes, what body parts ______________________________
Yes
No
Have you had any treatment since the accident?
Describe: ____________________________
________________________________________________________________________________________
Have you lost any time from work as a result of the accident?
Yes
No How much time? _____ days.
Please turn over
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal