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Name Date
Date of Accident Time am pm Location of Accident
AUTO INJURY
Were you: Driver Passenger Pedestrian
Were you struck from: Behind Right Side Left Side Front Parked
Did your car strike the others involved: Yes No Undetermined
Did the other car strike yours: Yes No Undetermined
ON-THE-JOB INJURY
How did the injury occur?
Did you report the injury to your foreman or employer: Yes No
Employer: Address:
OTHER
Describe the circumstances of the accident (Be Specific):
CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT
| Headache | Sleeping Problems | Lights Bother Eyes | Diarrhea |
| Neck Pain | Head Too Heavy | Loss of Memory | Feet Cold |
| Neck Stiff | Pins & Needles in Arms | Ears Ringing | Hands Cold |
| Dizziness | Pins & Needles in Legs | Face Flushed | Stomach Upset |
| Back Pain | Numbness in Fingers | Buzzing in Ears | Constipation |
| Nervousness | Numbness in Toes | Loss of Balance | Cold Sweats |
| Tension | Shortness of Breath | Fainting | Fever |
| Irritability | Fatigue | Loss of Smell | Other |
| Chest Pain | Depression | Loss of Taste |
Did you require post-accident hospitalization? Yes No
Have you lost any days of work? Yes No If Yes, through
INSURANCE INFORMATION
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
Signature ______________________________