top of page

AUTOMOBILE/PI ACCIDENT or WORK COMP FORM

Personal Injury Form

YOUR INFORMATION

Where were you sitting in your vehicle during the accident?
Were you wearing a seatbelt?
Direction your car was going:
Were were you looking at the time of the impact?
Did you hit any of these in the car?
Did your head hit anything in the car?
Did you lose consciousness during the accident?
Airbag deployed?
Was your vehicle towed?
Where the police notified?
If yes, accident report created?
Ambulance at the scene?
Where you hospitalized?
Check symptoms you have noticed since the accident:

SIGNATURE

bottom of page