Uninsured Motorists Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

When and where did the accident occur?

What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?

Were you driving? If not, where were you sitting in the vehicle?

Who owns the vehicle? Was it insured on the day of the accident?

Please provide your insurance company, agent's name, address, and telephone number.

If you are unable to identify the vehicle's driver or owner: did the vehicle make physical contact with yours?

Did the police come to the scene of the accident?
Yes  No 

Were any citations issued or arrests made?

Was either driver found to be at fault for a hazardous action? Do you have a copy of the police report?

Were you injured in the accident?

Were you taken to the hospital? How were you taken to the hospital?

What medical treatment have you received? Are you currently receiving medical treatment?

Were you insured on the day of the accident?
Yes  No 

How many vehicles did you have insured at the time and under how many different policies?

Did you have uninsure and/or underinsured motorist coverage at the time of the accident? If so, at what limits?

Are you currently under a physician's care for the injuries sustained in the accident? What is your prognosis?

Did you miss any work because of the accident?

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