Automobile Collision Worksheet


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Automobile Collision Worksheet Personal Information Name of Injured Person: If a minor, a parent's name: Spouse\s name: Mailing address: Phone Date of birth: Social security number: Employer's name: Employer's address: Collision Information Date of collision: Time of collision: Location of collision: Exact location: Collision was investigated by the Highway Patrol. Collision was investigated by the Police. Collision was investigated by Other. Who was driving the car you occupied: Name of driver of other car, if any: Describe the collision: Names of witnesses: Injuries and Losses Nature of your injuries: Amount of medical bills to date: I am still being treated: By whom: My car was involved and the damages are estimated at: Other property damage or loss: Have you settled your car or property damage claim: I have lost income. How much: Insurance Company insuring the car you occupied: Adjuster's name: Full Coverage: Other: I have given a statement. They have my bills. I have health and/or accident insurance. Medical Information Emergency room physician no. 1: (if any) Address: Hospital: Emergency room physician no. 1: (if any) Address: Hospital: Hospitals admitted to because of this injury: (list all) Treating Physicians for this injury: (list all) List all physicians that have treated you in the past 10 years: List all hospitals admitted to in the last 10 years: Family Physician:
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