Auto Accident Claim Form Personal Information First Name Last Name Email Phone ZIP Code Certificate ID Your unique certificate identification number Certificate URL Web address where your certificate is hosted Accident Details Accident Date Less than 1 year Less than 2 years Less than 3 years Vehicles Involved Injury Cause Car Accident Motorcycle Accident Truck Accident Bicycle Accident Pedestrian Accident Passenger Accident Your Role Driver Passenger Pedestrian Injury Information Injured? Yes No At Fault? Yes No Medical Treatment? Yes No Primary Injury Back/Neck Pain Broken Bones Cuts/Bruises Headaches Memory Loss Loss of Limb Other Legal Information Have Attorney? Yes No Settled with Insurance? Yes No Signed Retainer? Yes No Other Driver Insured? Yes No Unknown Want Attorney? Yes No Additional Comments Submit Claim
