Claim Form - Auto Accident

for Your State

This Claim Form for Auto Accident will serve as formal notice to the other party's insurance company that an auto accident has occurred. This claim form is set-out in an easy to use letter format and contains all relevant information concerning the auto accident.

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This Claim Form for an Auto Accident is for use by an attorney representing a client or an individual who has incurred injuries from an automobile accident. This claim form will serve as formal notice of the accident and is sent to the other driverís insurance company. This form contains all pertinent information regarding the auto accident including where it occurred, date of occurrence, the facility where treatment was received and the names of any treating physicians. It also contains a short description of the injured party and how the auto accident has affected his or her life. It is vital that all details regarding an auto accident be memorialized in writing. A written Claim Form after an Auto Accident will be useful in the event litigation is filed.

This Claim Form for Auto Accident includes the following:
  • Insurance Company: Sets out the name and address of the other driverís insurance company and references the driverís name, policy number and date of the accident;
  • Accident Description: Sets out a detailed description of the accident including the date, how the accident happened and relevant information obtained from the police report;
  • Treating Hospital/Physician: Sets out a description of treatment received, name of attending physician, medications prescribed and follow-up instructions;
  • Follow-Up Treatment: Sets out any follow-up doctor visits or physical therapy necessitated by the accident;
  • Description of Injury Party: A short rundown about how the injury has changed the partyís life (absence from work, inability to perform household chores and economic hardships);
  • Demand for Damages: A demand for damages including payment for lost wages, medical expenses and mental anguish;
  • Signature: The claim form must be signed by the attorney or individual involved in the auto accident.

Protect Your Rights by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Instructions and Checklist
  2. Claim Form for Auto Accident
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 CLAIM FORM FOR AUTOMOBILE ACCIDENT  Against Third Party Insurer
 
Your name
Address
Telephone
Email
SENT VIA [FACSIMILE, ELECTRONIC MAIL, US MAIL, EXPRESS MAIL]
 
[Date]
 
Name of Insurance Co.
Representative Name [if available]
Address
 
 
RE:
 
Your Name:
Their Insureds Name:
Their Insureds Policy Number:
Date of Accident:
 
 
Dear [Insert Name of Representative]:
 
This letter is to serve as notification and claim for damages I received as a result of the negligence of your insured, [insert name], on [insert date].
 
On [insert date] [describe accident] e.g. On February 3, 2004, I was driving west on Interstate 90. Your insured at the time was heading North on Bay Rd. When your insured reached the intersection of 90 and Bay Rd, he failed to observe a stop sign and his vehicle struck my vehicle causing substantial damage to my vehicle. A police report of the accident cites your insured as being in violation of [insert law].  Subsequently, I was treated by [insert name] for injuries to [insert injuries] and transported to [insert name of hospital, if applicable].  See attached police report.
 
[INSERT NAME OF TREATING HOPSITAL]
 
[Describe treatment at hospital], e.g. After being transferred to Bayview Hospital, I was seen by Dr. Ferguson. She had x-rays of my neck and shoulder.  Her diagnosis of my injuries was that I had a sprained shoulder and neck. She prescribed [insert medication] and ordered three days of bed rest. I was instructed to see [insert follow- up doctor] See attached Emergency Room Medical Report.
 
INSERT NAME OF FIRST PHYSICIAN
 
On [insert date], I saw [insert name of doctor, address] for injuries to [insert injuries].  Dr. Smith noted that I had [insert injuries] and that I would need [insert treatment, e.g. three weeks of physical therapy].  I indicated to the [insert name of Doctor] that I had [insert type of pain]. He prescribed [insert medication] for pain and to reduce swelling [if applicable]. [NOTE: If pre-existing condition, explain how accident has aggravated condition].
 
On [insert date], I saw Dr. Smith again for my injuries due to the accident on [insert date]. [Describe any follow-up diagnosis, treatment, etc.]
See attached Medical Records.
 
INSERT NAME OF SECOND PHYSICIAN [if, applicable]
 
INSERT NAME OF PHYSICAL THERAPIST [if applicable]
 
On [insert date], I was seen by [insert name] for [insert treatment including number of times as well as any follow-up visits].
 
INSERT YOUR NAME
 I am [insert age].  Prior to the accident, I was able to [insert activities, e.g. bowling three times a week, gardening, clean my house, golfing]. I had no ailments or injuries. I worked [full-time or part-time] as a [insert occupation]. After [insert date of accident], I have been unable to [insert all activities you no longer can engage in]. I have also missed several days of work. See attached documentation [attach proof of absences, if applicable]. [If married include explanation of spouses contribution to assist you as well as loss of intimidate contact  e.g. My spouse, [insert name] has take over chores that I performed around the house. As newlyweds, we have also stopped being intimate.  Prior to accident we were intimate three times a week.  After the accident, we no longer engage in intimate acts].
 
Due to your insureds negligence, I have suffered emotional and physical harm and hereby demand damages for your insureds negligence in the amount of [insert amount] (Add the following: Economic damages: damages to vehicle; medical and prescription bills not covered by your insurer, lost wages, etc.; Non-economic damages: physical pain, mental anguish, physical impairment]. [Optional clause: Additionally, my spouse demands damages in the sum of [insert amount] for loss of consortium and loss of service]. If you need further information in to evaluate this claim, please contact me.
 
Please act accordingly.
 
 
Sincerely,
 
[Insert name]
Number of Pages3
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28059
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