Personal Injury Pros: Accident Claim Worksheet

Accident Claim Worksheet

With all the stress and confusion an accident creates, it's easy to misplace letters and lose information. Let this worksheet be your guide and help keep you organized so that you can sit down with your lawyer and discuss the accident and what steps to take next. Please feel free to fill out the form and print it out for your reference.

Accident Information

Date of Accident:
Accident Location:

Were the police called to the scene? yes no
Was an ambulance called to the scene? yes no
How did the accident occur?

Passengers in your vehicle:
Name of passenger A (name, address and phone):
Passenger B (name, address and phone):
Passenger C (name, address and phone):

Passengers in other Vehicle (s) :
Passenger A (name, address and phone):
Passenger B (name, address and phone):
Passenger C (name, address and phone):

Person Responsible For Accident

Name:

Address:

Phone Number:

Insurance Company:

Policy Number:

Name of Car's
Registered Owner:

Witnesses

Name:

Address:

Phone Number:

Name:

Address:

Phone Number:

Your Auto Insurance Information

Company Name:
Address:
Phone Number:
Claim Number:
Adjuster:
If Auto Accident, Limited or Full Tort Option Copy of Declaration Page of Policy

Communications With Any Insurance Company
Date Sent/Received:
Comments:

Outcome:

Date Sent/Received:
Comments:

Outcome:

Medical Information
Part of Body Injured:
When Did the Pain Begin?
Have You Had Similar Injuries In The Past? yes    no
Did You Go To The ER? yes   no
Date of Visit:
Did You Visit a Doctor? yes   no
Name of Doctor:
Date of Visit:
Prescribed Treatment:

Medical Insurance Information

Name:
Address:
Phone Number:
Policy:
Claim Number:
Was the Claim Approved? yes no If No, Reason For Denial:

Wage Loss

Employer Name:
Employer Address:
Title/Position:

Hours/Days Missed Due To Accident:
Were You Paid For The Days You Were Out? yes no
If No, Approximately How Much Pay Did You Lose?
Did a Doctor Order Disability Leave? yes no
Name of Doctor Ordering Leave:

Please print this form and keep it as a reference.

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