Jeffrey G. Haverson - Attorney at Law
Initial Client Evaluation

Motor Vehicle Accident Form

Instructions: Please supply all information that is not marked ("Optional"). Forms submitted with missing information can NOT be processed or responded to.

Date of Accident or Auto_Injury:

Place of Accident:

Street:

City: State: Zip Code:

Name of Injured Party:

First Name: Middle Initial: Last Name:

Home Address:

Street: Apt. :

City: State: Zip Code:

Tel. # (w/ area code):

Alt. #: (w/ area code):

E-mail Address:

Description of Accident and Injuries:

Additional Accident Information:

Police at the scene? Yes No           Tickets issued? Yes No

Were you ticketed? Yes No           Was other driver ticketed? Yes No

Was your driver ticketed? (Optional - If applicable)    Yes No

If the answer to any of these questions is "Yes," please explain:



Were there passengers in your vehicle?       Yes     No

Were you a passenger in someone else's vehicle?        Yes       No

- If yes, give details.

Vehicle Information:

Your Vehicle: Year Make: Model:

Damage, in dollars (Optional - If known)

Other Vehicle: Year Make: Model:


Description of your injuries:



Hospital?    Yes     No          Doctor?    Yes    No

How? (Optional - If applicable)    Ambulance     Given a ride     Drove myself


Insurance Information:

Did you have auto insurance at the time of the accident?     Yes   No

If so, through what company ?(Optional)

Did the other driver have auto insurance?    Yes No Unknown

If so, through what company? (Optional)

Again, please be reminded that ALL information that is not marked "Optional" MUST be provided. If you are unsure if you have answered all necessary questions, please review this form before submitting it. Thank you.

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