Accident Information Form
(If you need more space, add as many pages as necessary.)
Accident date ___________________, 200___
Accident Time ______________a.m./p.m.
Location ________________________________________________
County _________________________________________________
State ________________________
The Other Driver (Car #1)
Name __________________________________________________
Address _________________________________________________
City _______________________ State _______ Zip _____________
Telephone _____________________________________________
Driver's License Number ______________________ State ________
Owner of Car #1, if different from Driver #1
Name __________________________________________________
Address _________________________________________________
City _______________________ State _______ Zip _____________
Telephone _____________________________________________
The Other Car (Car #1)
License Plate Number ____________________________________
State ___________ Expiration ______________________________
Make/Model/Year of Car #1 ________________________________
Insurance Coverage for Car #1
Carrier: ________________________________________________
Policy Number ___________________________________________
Agent's Name____________________________________________
Agent's Phone___________________________________________
(If more than one car was involved, collect the same information for each of the other drivers, owners and cars. Attach as many pages as necessary.)
Police Department That Responded __________________________
Police Officer's Name ______________________________________
Badge Number _________________________________
Where your car was towed to _______________________________
City __________________________________ State _____________
Company Name __________________________________________
Company Phone Number ___________________________________
Witnesses
Witness #1 Name ______________________________________
City _______________________ State _______ Zip ___________
Telephone _____________________________________
Witness #2 Name ______________________________________
City _______________________ State _______ Zip ___________
Telephone _____________________________________
Witness #3 Name ______________________________________
City _______________________ State _______ Zip ___________
Telephone _____________________________________
What did the other driver(s) say about how the accident happened?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Describe the damage to the other car(s)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
THINGS TO DO AFTER YOU GET HOME
1. Call your insurance company to report the accident and make a claim.
Write down the name of the person you talked
to:
_______________________________________________________,
the date _________________________,
the time _________________________,
and the claim number _____________________________________.
2. Call the other driver and verify that the information given was correct.
DO NOT TALK ABOUT HOW THE ACCIDENT HAPPENED OR YOUR INJURIES.
3. If you are hurt set up an appointment with a doctor as soon as possible.
Doctors Name ___________________________________________
Telephone Number _______________________________________
Appointment date and time ________________________________
4. CALL David Bert Havas at 801.395.0556 (toll free: 888.923.8411).
ALWAYS TALK WITH YOUR LAWYER BEFORE TALKING WITH THE OTHER INSURANCE COMPANY, EXCEPT TO SAY WHERE YOUR CAR MAY BE SEEN FOR AN APPRAISAL:
5. Check with the tow company about your car, make sure it is still there and let them know you are working on getting it out.
6. Call your employer and let them know you have been in an accident.
7. Write down everything that happens, how you feel, who you have talked to and about what.
NEVER GIVE A RECORDED STATEMENT TO AN INSURANCE COMPANY UNTIL YOU HAVE TALKED TO A LAWYER. WE WOULD BE PLEASED TO DISCUSS YOUR OPTIONS WITH YOU:
DAVID BERT HAVAS, P.C.
533 26th Street, Suite 100
Ogden, Utah 84401
Phone: 801.395.0556
Toll Free: 888-923-8411
Fax: 801.393.4004
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Print extras and keep copies in your car. You never know when you may need to collect this type of information because you are involved in a car crash or you witness one.
DISCLAIMER
Although we strive to provide the most accurate information possible in these web pages, every case is different so the information may not apply to your particular set of facts. This site is merely a resource for further inquiry. NO LEGAL SERVICES ARE BEING PROVIDED. Your inquiry and any response we may provide does not create an attorney-client relationship.