Accident Claim Worksheet
What Happened
Date of accident: _________________________
Description of accident: _________________________
Names of parties involved: _________________________
Names of witnesses: _________________________
Location of accident: _________________________
Time of accident: _________________________
Weather condition (if outside): _________________________

People Responsible for the Accident
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Insurance company: ___________________	Policy number: ___________________
Auto license: _________________________
What person did: ___________________________________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Insurance company: ___________________	Policy number: ___________________
Auto license: _________________________
What person did: ___________________________________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Insurance company: ___________________	Policy number: ___________________
Auto license: _________________________
What person did: ___________________________________________________

Witnesses
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Date of first contact: _________________________
Written statement: [   ] yes [   ] no
What person saw: ___________________________________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Date of first contact: _________________________
Written statement: [   ] yes [   ] no
What person saw: ___________________________________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone (work): __________________	(home): ____________________________
Date of first contact: _________________________
Written statement: [   ] yes [   ] no
What person saw: ___________________________________________________

Medical Treatment Providers
Name: _________________________
Address:	_________________________
	_________________________
Telephone: _________________________
Date of first visit: _________________________
Date of most recent or last visit: _________________________
Person to be contacted for medical records: _________________________
Date requested: __________________ 	Date received: ___________________
Person to be contacted for medical billing: _________________________
Date requested: __________________ 	Date received: ___________________
Reason for treatment and prognosis: _________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone: _________________________
Date of first visit: _________________________
Date of most recent or last visit: _________________________
Person to be contacted for medical records: _________________________
Date requested: __________________ 	Date received: ___________________
Person to be contacted for medical billing: _________________________
Date requested: __________________ 	Date received: ___________________
Reason for treatment and prognosis: _________________________
.......................................................................................................................................................
Name: _________________________
Address:	_________________________
	_________________________
Telephone: _________________________
Date of first visit: _________________________
Date of most recent or last visit: _________________________
Person to be contacted for medical records: _________________________
Date requested: __________________ 	Date received: ___________________
Person to be contacted for medical billing: _________________________
Date requested: __________________ 	Date received: ___________________
Reason for treatment and prognosis: _________________________

Other Party's Insurance Company (First Party)
Company name: _________________________
Address: _________________________
	  _________________________
Telephone: _________________________
Insured: ________________________	Claim number: _________________________
Adjuster: _________________________
Date demand letter was sent: _________________________
Settlement amount: ________________	Date accepted: ____________
Other Party's Insurance Company (Second Party)
Company name: _________________________
Address: _________________________
	  _________________________
Telephone: _________________________
Insured: ________________________	Claim number: _________________________
Adjuster: _________________________
Date demand letter was sent: _________________________
Settlement amount: ________________	Date accepted: ____________
Communications With Insurer
Date: _________________________
If oral, what was said: _____________________________________

Communications With Insurer
Date: _________________________
If oral, what was said: _____________________________________

Communications With Insurer
Date: _________________________
If oral, what was said: _____________________________________

Communications With Insurer
Date: _________________________
If oral, what was said: _____________________________________

Communications With Insurer
Date: _________________________
If oral, what was said: _____________________________________

Losses
Describe damage to your property: _________________________
Do you have photos showing damage [   ] yes [   ] no
If Repairable
Estimates for repairs (name of repair shop and amounts of estimates): _____________________________________
Actual
Repair bills (name of repair shop and amounts of bills): _________________________
If totaled:
	Value at the time destroyed: _________________________
	Documentation of value: _________________________