Claim Form - Auto Accident

This Claim Form for an Auto Accident is for use by an attorney representing a client or an individual who has incurred injuries in an automobile accident. This claim form serves as notice of the accident and is sent to the other driver’s insurance company. This claim form contains information regarding the accident including the date and where it occurred, facility where treatment was received and names of treating physicians. It also contains a short description about the injured party and how the auto accident has affected him or her. It is important that the details of an auto accident be set out in writing. A written Claim Form after an Auto Accident will prove helpful if litigation is filed.

This Claim Form for Auto Accident includes:

• Insurance Company: The name and address of the other driver’s insurance company and references to driver’s name, policy number and date of the accident;
• Accident Description: Description of the accident including how it happened and relevant information from the police report;
• Treating Hospital/Physician: Medical treatment received, name of attending physician, medications prescribed and any follow-up instructions;
• Follow-Up Treatment: Follow-up doctor visits or physical therapy necessitated by the accident;
• Description of Injured Party: A short synopsis about how the injury has changed the injured party’s life;
• Demand for Damages: Demand for damages including payment for lost wages and mental anguish;
• Signature: The claim form must be signed by the attorney or individual involved in the auto accident.

This attorney-prepared packet contains:

1. General Instructions and Checklist
2. Claim Form for Auto Accident

State Law Compliance: This form complies with the laws of all states

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• Includes:

  √ Free Checklist

• State:

   All
  

  Number of Pages:

   3

• File Types Included:

  
  √ Microsoft Word
  √ Adobe PDF
  √ WordPerfect
  √ Rich Text Format
  

• Compatible with:

  Windows and Mac OS