AUTO ACCIDENT

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					                              AUTO ACCIDENT

PATIENT NAME: ________________________________ BIRTHDATE: _________________

PLEASE PROVIDE THE FOLLOWING INFORMATION:

AUTO INSURANCE COMPANY: __________________________________________________

ADDRESS: ___________________________________________________________________

_____________________________________________________________________________

PHONE #: ____________________________________________________________________

NAME OF ADJUSTOR: _________________________________________________________

NAME OF POLICYHOLDER: _____________________________________________________

CLAIM #: _____________________________________________________________________

DATE OF ACCIDENT: __________________________________________________________

PLEASE GIVE A BRIEF DESCRIPTION OF THE ACCIDENT: ___________________________

_____________________________________________________________________________

_____________________________________________________________________________

IF THERE WAS A SECOND AUTO INVOLVED IN THIS ACCIDENT AND YOU HAVE THEIR
INSURANCE INFORMATION, PLEASE PROVIDE IT HERE: ____________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

SIGNATURE: _____________________________________ TODAY’S DATE: _____________




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