Auto Accident Report Form Page 3
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4Risk Management | EGS
E-mail:
risk.management@oregon.gov
PO Box 12009
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Find this form on the Web at:
503-373-7475
503-373-7337 fax
OREGON AUTO ACCIDENT REPORT FORM
Bodily Injury Questionnaire: IMPORTANT: We are required by federal law to obtain the information in questions
15 through 17. Failure to provide this information will result in delays in resolving your claim. You can find further
Centers for Medicare and Medicaid Services - Home
Website.
information at
15. Last Name
First name
Middle initial
16. Date of Birth (mm/dd/yyyy)
17. Gender
M
F
18. Is this related to an auto accident? (If no, skip to question 22)
19. If yes, where were you seated in vehicle?
Driver Front right passenger Rear right passenger Rear left passenger
Other
20. Seatbelt used? Yes
No
What kind? Lap
Shoulder
None
21. Did the airbag deploy?
Yes
No
22. Describe your injury:
23. When did you first notice you were injured?
24. Have you sought medical treatment?
Yes
No
25. If yes, list the medical providers you have seen:
26. Approximate amount of medical costs incurred to date:
27. Is future treatment expected?
28. If yes, explain:
Yes
No
29. Do you have any prior injuries to the injured body part(s)?
Yes
No
30. If yes, explain:
31. Any other information you would like to provide to us:
Page 3 of 4
Revised 3/16/2016
Form No. DAS-RM Accident Form
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