Accident Claim Worksheet

Accident Claim Worksheet

This worksheet will help you keep track of the all-important details of your accident.  Use this form to keep track of contact information of the parties and witnesses involved along with details from insurance companies and other information you will need to process an accident claim.

You can save and edit the form before you buy--just create a Nolo.com account. It's easy, free, and there's no obligation to buy anything. If you purchase the form, you'll be able to print, send, or download it.

See below for a full product description.

Accident Brief

Date of accident: 

Description of accident: 

Names of parties involved: 

Names of witnesses: 

Location of accident: 

Time of accident: 

Multiple Selection
Label Contract Text
Weather Conditions

Weather condition: 

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responsible party

People Responsible for the Accident

Alternate Selection
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One

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

Two

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

Three

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

Four

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company: 
Policy number: 
Driver's license: 

What the person did: 

Five

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company:  
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company: 
Policy number: 
Driver's license: 

What the person did: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Insurance company: 
Policy number: 
Driver's license: 

What the person did: 

Multiple Selection
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witnesses

Witnesses

Alternate Selection
Label Contract Text
One

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

Two

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

Three

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

Four

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

Five

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Email address: 
Date of first contact: 
Written statement: 

What person saw or heard: 

Multiple Selection
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medical contacts

Medical Contacts

Alternate Selection
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One

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested:  
Date received: 
Person to be contacted for medical billing: 
Date requested:  
Date received: 
Reason for treatment and prognosis: 

Two

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested:  
Date received: 
Person to be contacted for medical billing: 
Date requested:  
Date received: 
Reason for treatment and prognosis: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested:  
Date received: 
Person to be contacted for medical billing: 
Date requested: 
Date received: 
Reason for treatment and prognosis: 

Three

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested:  
Date received: 
Person to be contacted for medical billing: 
Date requested:  
Date received: 
Reason for treatment and prognosis: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested: 
Date received: 
Person to be contacted for medical billing: 
Date requested: 
Date received: 
Reason for treatment and prognosis: 

----------------------------------------------------------------------------------

Name: 
Address: 
Phone: 
Date of first visit: 
Date of most recent or last visit: 
Person to be contacted for medical records: 
Date requested:  
Date received: 
Person to be contacted for medical billing: 
Date requested:  
Date received: 
Reason for treatment and prognosis: 

Multiple Selection
Label Contract Text
other party's insurance

Other Parties' Insurance

Alternate Selection
Label Contract Text
One

Insurance company name: 
Address: 
Phone: 
Name of insured party:  
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

Two

Insurance company name: 
Address: 
Phone: 
Name of insured party:  
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

----------------------------------------------------------------------------------

Insurance company name: 
Address: 
Phone: 
Name of insured party:  
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

Three

Insurance company name: 
Address: 
Phone: 
Name of insured party:  
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

----------------------------------------------------------------------------------

Insurance company name: 
Address: 
Phone: 
Name of insured party:  
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

----------------------------------------------------------------------------------

Insurance company name: 
Address: 
Phone: 
Name of insured party: 
Claim number: 
Adjuster: 
Date demand letter was sent: 
Settlement amount: $ 
Date accepted: 

Multiple Selection
Label Contract Text
communications with insurer

Communications With Insurers

Alternate Selection
Label Contract Text
One

Date:  
Name of employee: 

If oral, what was said: 

Two

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

Three

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date: 
Name of employee: 

If oral, what was said: 

Four

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date: 
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

Five

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date: 
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

----------------------------------------------------------------------------------

Date:  
Name of employee: 

If oral, what was said: 

Multiple Selection
Label Contract Text
losses

Losses

Description of damages to your property:

Alternate Selection
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Yes

I have photos showing damage.

No

I don't have photos showing damage.

Multiple Selection
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if repairable

If Repairable

Alternate Selection
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Yes

Estimates for repairs (name of repair shop and amounts of estimates): 

Actual repair bills (name of repair shop and amounts of bills): $

If totaled:

Value at the time of damage: $

Documentation of value: 

No

The damage is not repairable. The value at the time of destruction: $.

 

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1-Year Subscription

Price: $29.99

If you’re injured in an accident, it can be hard to keep track of all the details. What day was it that you called the insurance company, and who did you talk to? Where’s the phone number of the bystander who saw the car that plowed into yours? When did the doctor say to make another appointment? There are so many names, numbers, dates, and forms.

Whether you’re in a car crash, “slip and fall” accident, or other mishap, you need to keep all this information straight. Having it could mean the difference between asserting a successful claim with your insurance company (or in court) and being uncompensated for your loss or injury.

Use this form to record the names, addresses, and phone numbers of the other person or business involved, witnesses, your insurance company, and others. You can also make notes of communications with them, dates of various events, conversations, details from insurance companies, and other information you will need to get compensation for your loss.

Important to Know:

  • This form is for your personal reference, to help you stay on top of matters; it’s not part of your claim.
  • Get witness statements in writing as soon as possible.
  • When you're ready to inform the appropriate insurance company of an accident, use the "Notice of Insurance Claim."

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