Fill out each section thoroughly and to the best of your ability.
Forms must be completed in a single session. Information will not be saved.
Estimated Completion Time: 20 minutes
You will need the following information:
Driver information
Vehicle information
Accident information
Injury Information
Healthcare Providers
Prior Medical History
Prior Physicians
Income Benefits
Medical Insurance Coverage
Education
Employment
Once the form is completed, signed and submitted, you will receive an email of acknowledgement.
If your injuries require immediate attention, go directly to the nearest hospital for medical treatment or call 911.