Accident claim form

accident claim form

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This Claim Form for an Auto Accident is for use by an attorney representing a client or an individual who has incurred injuries from an automobile accident. This claim form will serve as formal notice of the accident and is sent to the other driver’s insurance company. This form contains all pertinent information regarding the auto accident including where it occurred, date of occurrence, the facility where treatment was received and the names of any treating physicians. It also contains a short description of the injured party and how the auto accident has affected his or her life. It is vital that all details regarding an auto accident be memorialized in writing. A written Claim Form after an Auto Accident will be useful in the event litigation is filed.

This Claim Form for Auto Accident includes the following:
  • Insurance Company: Sets out the name and

    address of the other driver’s insurance company and references the driver’s name, policy number and date of the accident;

  • Accident Description: Sets out a detailed description of the accident including the date, how the accident happened and relevant information obtained from the police report;
  • Treating Hospital/Physician: Sets out a description of treatment received, name of attending physician, medications prescribed and follow-up instructions;
  • Follow-Up Treatment: Sets out any follow-up doctor visits or physical therapy necessitated by the accident;
  • Description of Injury Party: A short rundown about how the injury has changed the party’s life (absence from work, inability to perform household chores and economic hardships);
  • Demand for Damages: A demand for damages including payment for lost wages, medical expenses and mental anguish;
  • Signature: The claim form must be signed by the attorney or individual involved in the auto accident.


Category: Accident

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