PLAINTIFF DRIVER:
Name: Home Phone: ( )
Address:
Cell Phone #: ( ) Email:
Date of Birth: I.D./Driver License #: State:
Social Security #: Marital Status: Spouse:
Emergency Contact: Phone #:
EMPLOYMENT:
Employer: Phone #: ( )
Address:
Supervisor: Length of Employment:
Title/Occupation: Duties:
For Loss of Earnings/Wages Claim Pay Rate: (Weekly, Monthly, Commission, Etc.)
PREVIOUS ACCIDENTS AND INJURIES:
INJURIES RESULTING FROM THIS ACCIDENT:
Did an ambulance arrive at the scene? If so, were you transported?
Ambulance Company Name: Hospital/Location:
Doctor #1:
Did you have health insurance? Information:
Medi-Cal/Medicare # (if applicable): Copy of card?
AUTOMOBILE INSURANCE:
Insurance carrier: Policy #
Agent/Adjuster: Phone #: ( )
Policy period from : to: Claim?
Coverage: ☐ Liability ☐ BI/PD ☐ Med Pay ☐ UM ☐ UIM ☐ UIM PD Deductible:
PLAINTIFF’S VEHICLE:
Year: Make: Model: Color:
License Plate #: State: Vehicle ID #:
Registered Owner: Legal Owner:
Present location of the vehicle:
Vehicle damage description: Approximate Estimate: $
Towing Company: Towing Fees Advanced: $
Rental Company: Rental Fees Advanced: $
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PASSENGER #1: Relation to Driver: Position in Car:
Name: Phone #: ( )
Address:
Date of birth: I.D./Driver License #: State:
Social Security #: Marital Status: Spouse:
Emergency Contact: Phone #: ( )
Cell Phone #: ( ) Email:
Employer: Phone ( )
Address:
Title Occupation: Duties:
Previous Accidents & Injuries:
Injuries from this accident:
For Loss of Earnings/Wages Claim Pay Rate: (Weekly, Monthly, Commission, Etc.)
Did an ambulance arrive at the scene? If so, were you transported?
Ambulance Company Name: Hospital/Location:
Doctor #1:
Did you have health insurance? Information:
Medi-Cal/Medicare # (if applicable): Copy of card?
PASSENGER #2: Relation to Driver: Position in Car:
Name: Phone #: ( )
Address:
Date of birth: I.D./Driver License #: State:
Social Security #: Marital Status: Spouse:
Emergency Contact: Phone #: ( )
Cell Phone #: ( ) Email:
Employer: Phone ( )
Address:
Title Occupation: Duties:
Previous Accidents & Injuries:
Injuries from this accident:
For Loss of Earnings/Wages Claim Pay Rate: (Weekly, Monthly, Commission, Etc.)
Did an ambulance arrive at the scene? If so, were you transported?
Ambulance Company Name: Hospital/Location:
Doctor #1:
Did you have health insurance? Information:
Medi-Cal/Medicare # (if applicable): Copy of card?
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DEFENDANT:
Name:
Address:
Driver License: Approximate age or D.O.B.:
Home Phone #: ( ) M/F: Race:
Employer Known: Work Phone: ( )
DEFENDANT 'S VEHICLE:
Year: Make: Model: Color:
License #: Vehicle ID #:
Name and Address of Registered Owner:
Description of vehicle damage:
Was the vehicle towed form the scene?: if so, where?:
DEFENDANT'S PASSENGERS:
Name: Address:
Age: Injured?: if so, was he/she transported:
Name: Address:
Age: Injured?: if so, was he/she transported:
DEFENDANT'S INSURANCE:
Name of carrier: Policy:
Adjuster/Agent: Phone#: ( )
Address:
Policy Period from: to:
Has anyone from defendant's insurance contacted you?: If so, who?:
Was a recorded statement taken?: Did you sign a statement? Date of statement:
OTHER VEHICLES OR PROPERTY INVOLVED:
Owner: Type of Damage:
Address: Phone #: ( )
Insurance carrier: Policy #: ( )
Insurance Carrier: Policy 4:
Year: Make: Model: Color:
License #: Vehicle ID #:
ACCIDENT FACTS:
Date: Day: Time: a.m./p.m.
Place:
Weather: Dry: Sunny: Moist: Wet: Other:
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Hazard /Obstructions:
What street were you on? ☐ N/B ☐S/B ☐ E/B ☐ W/B
What street was the defendant on? ☐ N/B ☐S/B ☐ E/B ☐ W/B
Number of lanes for each direction of the street? Your Side: Other party:
Which lane were you in? Which lane was the other party in?
Traffic Signal: Type: For which direction:
ACCIDENT DESCRIPTION:
What did you do when you first realized the danger?
What was your speed? Other party's speed?
Where was the point of' impact on your car? Other party?
Skid marks? Your car: Length: Other car:
WITNESSES:
Did anyone admit fault at the scene? If so who?
What was said:
Police arrived? Report made? which agency?
Was a citation issued? It so, to whom?
Did you indulge in any alcoholic beverage prior to the accident? If so, how much,
where and when:
Did the other party appear to be under the influence at the time of the accident?
If so, who? Based on:
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REFERRED BY:
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