Accidental Injury Form

Name

Date

Date of Accident

Time

Location of Accident

Were you:

Driver Passenger Pedestrian

Were you struck from:

Did your car strike the others involved?

Yes No Undetermined

Did the other car strike yours?

Yes No Undetermined

How did the injury occur?

Did you report the injury to your foreman or employer?

Yes No

Employer

Address

Describe the circumstances of the accident (Be Specific):

Did you require post-accident hospitalization?

Yes No

Have you lost any days of work?

Yes No

If Yes, from

through

Your Insurance Company

Address

Secondary Insurance Company

Address

Auto Insurance Company

Address

Other Party's Name

Address

Other Party's Ins. Co.

Address

Have you been contacted by an insurance adjustor regarding this claim?

Yes No

If yes, name of adjustor

Company

Do you have an attorney that has advised you in this case?

Yes No

If yes, attorney's name

Address

Auto Injury