Prefix
First Name
Middle Name
Last Name
Date of Birth
Phone Number
Email
Street Address
City
State/Region
Country
Zip/Postal Code
Date of Incident
Please upload a copy of your drivers license.
Please describe how the incident occurred.
Was a police report prepared?
Please upload a copy of the police report.
What, if anything was communicated between you and the potential defendant(s), law enforcement officers, firefighters, tow truck drivers and/or witnesses after the incident occurred.
Please upload any photos and/or videos of the scene of the incident.
Please upload any photos and/or videos showing property damages sustained to the vehicles involved in the incident.
On what date were you treated?
Where were you treated? Please include name of medical provider(s) and phone number.
What was your diagnosis?
What, if any, additional medical treatment has been recommended by your provider(s).
Please upload any medical bills and medical records related to injuries sustained in the incident.
Who is your health insurance carrier?
What is your health insurance policy number?
What is the phone number for your health insurance carrier?
Please upload a copy of your health insurance card.
Who is your automobile insurance carrier?
What is your automobile insurance policy number?
What is the phone number for your automobile insurance carrier?
Do you have uninsured/underinsured (UM/UIM) coverage on your automobile insurance policy? (Review your Declarations page)?
Please upload a copy of your automobile Insurance policy?
Who is the potential defendant's automobile insurance carrier?
What is the potential defendant's automobile insurance policy number?
What is the phone number for the potential defendant's automobile insurance carrier?
Please upload any additional evidence you believe is relevant to the incident - e.g., your hand written or electronic notes, any correspondence with auto insurers about the incident or witness statements.
If you have incurred or expect to incur lost wages due to injuries caused by the incident, please indicate the following: 1) your employer, 2) your job title, 3) your start date with current employer and 4) your annual salary or your hourly pay rate.
