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: 

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Weather Conditions

Weather condition: 

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responsible party

People Responsible for the Accident

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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: 

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witnesses

Witnesses

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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: 

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

What person saw or heard: 

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medical contacts

Medical Contacts

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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: 

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other party's insurance

Other Parties' Insurance

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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: 

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communications with insurer

Communications With Insurers

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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: 

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losses

Losses

Description of damages to your property:

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Yes

I have photos showing damage.

No

I don't have photos showing damage.

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if repairable

If Repairable

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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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