Auto Accident Form Your name Dates This Date of Accident Time of Accident City of Accident Street of Accident Did police come to the screne? Yes No Is there a police report? Yes No Did you go to the hospital? Yes No If yes, which hospital? Did you ride in an ambulance? Yes No If yes, mark what you recieved: MRI Scans X-Ray Blood Work Other Tests What injuries occured? Were you aware of the approaching collision? Yes No Did you experience a flash of light or 'explosion' in your head? Yes No Did you lose Consciousness? Yes No Did you suffer from any of the symptoms below? Select all that apply. Confused Disoriented Light Headed Dizzy Blurred Vision Ringing/bussing Ears Nauseated Changes in bowel/bladder How far in inches is the top of the headrest from your head? Aprox. Were you wearing your seatbelt? Yes No List the year make and model of the vehicle you were in. Was the car stopped at time of impact? Yes No If yes, was the drivers foot also on the brake? Yes No If no, estimate the speed of the vehicle you were in (MPH) If your vehicle was moving at the time of impact, was it: Slowing Down Gaining Speed Traveling at a steady speed Did any part of you body hit a part of the vehicle? Yes No If Yes, on what part of the automobile did your following body parts hit? Did you receive any injury or bruise from the seat belt? Yes No If yes, please describe Was your body pointed straight forward at the time of impact? Yes No What is the year, make and model of the other car? If the other vehicle was moving at the time of the collision, was it: Slowing down Gaining speed Traveling at a steady seed Please describe, to the best of your knowledge, what happened during this accident: Driver of other Vehicle's Name: Insurance Co: Policy #: Local Agent name Agent phone number Did they receive a ticket? Yes No Did you receive a ticket? Yes No Send
